Provider Demographics
NPI:1558733576
Name:MARGLIN, LISA MARIE (LPT)
Entity Type:Individual
Prefix:MISS
First Name:LISA
Middle Name:MARIE
Last Name:MARGLIN
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:BITONTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPT
Mailing Address - Street 1:PO BOX 235
Mailing Address - Street 2:
Mailing Address - City:HERALD
Mailing Address - State:CA
Mailing Address - Zip Code:95638
Mailing Address - Country:US
Mailing Address - Phone:209-395-8117
Mailing Address - Fax:
Practice Address - Street 1:6301 CUMBERLAND PL
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-3661
Practice Address - Country:US
Practice Address - Phone:209-640-1204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-29
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 38247311Z00000X
CAPT38249311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALPT38249Medicaid