MEDICARE: MS. LISA LA VENIA KUZAK

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	372600000X	Adult Companion

General Provider Information

NPI Number	:	1477762359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA LA VENIA KUZAK

Provider Business Mailing Address
First Line	:	188 S CLEVELAND AVE
Second Line	:
City	:	MOGADORE
State	:	OH
Zip	:	44260-1403
Country	:	US
Telephone Number	:	330-628-5305
Fax Number	:

Provider Business Practice Location Address
First Line	:	188 S CLEVELAND AVE
Second Line	:
City	:	MOGADORE
State	:	OH
Zip	:	44260-1403
Country	:	US
Telephone Number	:	330-628-5305
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	07/08/2007

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