MEDICARE: MISS LISA MARIE MARGLIN LPT

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	311Z00000X	Custodial Care Facility	PT 38247	CA
2	311Z00000X	Custodial Care Facility	PT38249	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558733576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS LISA MARIE MARGLIN LPT

Provider Business Mailing Address
First Line	:	PO BOX 235
Second Line	:
City	:	HERALD
State	:	CA
Zip	:	95638
Country	:	US
Telephone Number	:	209-395-8117
Fax Number	:

Provider Business Practice Location Address
First Line	:	6301 CUMBERLAND PL
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95219-3661
Country	:	US
Telephone Number	:	209-640-1204
Fax Number	:

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

Provider Enumeration Date	:	10/29/2015
Last Update Date	:	12/03/2019

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