Provider Demographics
NPI:1225735228
Name:PLACE, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 HAVEMANN RD
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45822-9300
Mailing Address - Country:US
Mailing Address - Phone:419-230-3914
Mailing Address - Fax:
Practice Address - Street 1:1950 HAVEMANN RD
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822-9300
Practice Address - Country:US
Practice Address - Phone:419-230-3914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS5509156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHS5509Medicaid