Provider Demographics
NPI:1417206400
Name:MIZADA INC
Entity Type:Organization
Organization Name:MIZADA INC
Other - Org Name:MIZADA ASSISTANT LIVING FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:LIGHTBOURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-336-5884
Mailing Address - Street 1:3726 SW MANAK ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-7705
Mailing Address - Country:US
Mailing Address - Phone:772-336-5884
Mailing Address - Fax:
Practice Address - Street 1:3726 SW MANAK ST
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-7705
Practice Address - Country:US
Practice Address - Phone:772-336-5884
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAH12155310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility