Healthcare Provider Details

I. General information

NPI: 1295170041
Provider Name (Legal Business Name): LARISA DENISE DEZAYAS COMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2013
Last Update Date: 05/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 W NATIONAL AVE
MILWAUKEE WI
53295-0001
US

IV. Provider business mailing address

1741 S 55TH ST
WEST MILWAUKEE WI
53214-5246
US

V. Phone/Fax

Practice location:
  • Phone: 414-384-2000
  • Fax:
Mailing address:
  • Phone: 414-803-0444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255R0406X
TaxonomyBlind Rehabilitation Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: