MEDICARE: LISSA COMPANY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1275271371
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LISSA COMPANY

Provider Business Mailing Address
First Line	:	2630 W BROWARD BLVD STE 203
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33312-1315
Country	:	US
Telephone Number	:	800-577-6271
Fax Number	:

Provider Business Practice Location Address
First Line	:	7593 HAMPTON BLVD
Second Line	:
City	:	NORTH LAUDERDALE
State	:	FL
Zip	:	33068-5586
Country	:	US
Telephone Number	:	845-405-9970
Fax Number	:	800-577-6271

Authorized Official
Title or Position	:	CEO
Name	:	MELISSA MIRAMBEAU-BROUSSARD
Credential	:	ADMINISTRATOR
Telephone Number	:	845-405-9970

Provider Enumeration Date	:	05/27/2022
Last Update Date	:	05/27/2022

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Directions to “LISSA COMPANY ” Practice Location

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