MEDICARE: LISA M PROVENZA-TABAK D.C.

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	111N00000X	Chiropractor	2661	OH

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
2	341935351-00	OTHER	OH	BWC

General Provider Information

NPI Number	:	1871583948
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA M PROVENZA-TABAK D.C.

Provider Business Mailing Address
First Line	:	3680 STARRS CENTRE DR
Second Line	:
City	:	CANFIELD
State	:	OH
Zip	:	44406-9514
Country	:	US
Telephone Number	:	330-702-0500
Fax Number	:	330-702-0575

Provider Business Practice Location Address
First Line	:	3680 STARRS CENTRE DR
Second Line	:
City	:	CANFIELD
State	:	OH
Zip	:	44406-9514
Country	:	US
Telephone Number	:	330-702-0500
Fax Number	:	330-705-0575

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

Provider Enumeration Date	:	10/28/2005
Last Update Date	:	06/11/2008

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