=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568787406
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LISA ARNETT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2010
-----------------------------------------------------
Last Update Date | 04/04/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1029 SHENANDOAH DR
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47905-4361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-412-8253
-----------------------------------------------------
Fax | 765-838-3886
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1029 SHENANDOAH DR
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47905-4361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-412-8253
-----------------------------------------------------
Fax | 765-838-3886
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO OWNER
-----------------------------------------------------
Name | MISS REGINA D CABELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 765-412-8253
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | J5CM918216-00
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------