Provider Demographics
NPI:1073677514
Name:FARIAS, LISA RENE (DC)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:RENE
Last Name:FARIAS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4337 FLAGSTAFF CV
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-4400
Mailing Address - Country:US
Mailing Address - Phone:260-485-9300
Mailing Address - Fax:
Practice Address - Street 1:4337 FLAGSTAFF CV
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-4400
Practice Address - Country:US
Practice Address - Phone:260-485-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002194A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN231870AOtherMEDICARE GROUP #
IN231870AOtherMEDICARE GROUP #
IN231870Medicare ID - Type Unspecified