=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891507828
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIZZMA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2025
-----------------------------------------------------
Last Update Date | 01/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 POWELL ST STE 600
-----------------------------------------------------
City | EMERYVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94608-1885
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 341-400-1392
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1900 POWELL ST STE 600
-----------------------------------------------------
City | EMERYVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94608-1885
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 341-400-1392
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | OLANREWAJU AGBAJE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 341-400-1392
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 247200000X
-----------------------------------------------------
Taxonomy Name | Other Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------