Provider Demographics
NPI:1497512248
Name:ROLLF, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ROLLF
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 1:3286 E GUASTI RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-8646
Mailing Address - Country:US
Mailing Address - Phone:909-479-3836
Mailing Address - Fax:
Practice Address - Street 1:3286 E GUASTI RD STE 100
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-8646
Practice Address - Country:US
Practice Address - Phone:909-479-3836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty