MEDICARE: LISA MERLIN HOUSE, INC.

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	324500000X	Substance Abuse Rehabilitation Facility	0748AD260003	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	S6B	OTHER	FL	BCBSFL PROVIDER NO.

General Provider Information

NPI Number	:	1730163379
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LISA MERLIN HOUSE, INC.

Provider Business Mailing Address
First Line	:	3101 N PINE HILLS RD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32808-3543
Country	:	US
Telephone Number	:	407-292-0109
Fax Number	:	407-293-5709

Provider Business Practice Location Address
First Line	:	3101 N PINE HILLS RD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32808-3543
Country	:	US
Telephone Number	:	407-292-0109
Fax Number	:	407-293-5709

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MRS. LISA E MERLIN
Credential	:
Telephone Number	:	407-292-0109

Provider Enumeration Date	:	12/06/2005
Last Update Date	:	08/22/2020

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