Provider Demographics
NPI:1275271371
Name:LISSA COMPANY
Entity Type:Organization
Organization Name:LISSA COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRAMBEAU-BROUSSARD
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:845-405-9970
Mailing Address - Street 1:2630 W BROWARD BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-1315
Mailing Address - Country:US
Mailing Address - Phone:800-577-6271
Mailing Address - Fax:
Practice Address - Street 1:7593 HAMPTON BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33068-5586
Practice Address - Country:US
Practice Address - Phone:845-405-9970
Practice Address - Fax:800-577-6271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-27
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service