Provider Demographics
NPI:1447392360
Name:LISENBY LLLP
Entity Type:Organization
Organization Name:LISENBY LLLP
Other - Org Name:LISENBY ON LAKE CAROLINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:H
Authorized Official - Last Name:SCHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-645-3211
Mailing Address - Street 1:1890 STATE ROAD 436
Mailing Address - Street 2:SUITE 300
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-2285
Mailing Address - Country:US
Mailing Address - Phone:407-645-3211
Mailing Address - Fax:407-628-2853
Practice Address - Street 1:1400 WEST ELEVENTH STREET
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-1896
Practice Address - Country:US
Practice Address - Phone:850-785-6121
Practice Address - Fax:850-747-3696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL4809310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020398001Medicaid