MEDICARE: BERNADETA LIS

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	385HR2060X	Child Intellectual and/or Developmental Disabilities Respite Care

General Provider Information

NPI Number	:	1609252592
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BERNADETA LIS

Provider Business Mailing Address
First Line	:	520 OXFORD CT
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48307-4527
Country	:	US
Telephone Number	:	248-909-8840
Fax Number	:

Provider Business Practice Location Address
First Line	:	520 OXFORD CT
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48307-4527
Country	:	US
Telephone Number	:	248-909-8840
Fax Number	:

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

Provider Enumeration Date	:	08/03/2015
Last Update Date	:	08/03/2015

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Directions to “ BERNADETA LIS ” Practice Location

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