Provider Demographics
NPI:1598880270
Name:STARK, LYSA (DC)
Entity Type:Individual
Prefix:DR
First Name:LYSA
Middle Name:
Last Name:STARK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:LYSA
Other - Middle Name:
Other - Last Name:NEMIROFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:17922 MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708
Mailing Address - Country:US
Mailing Address - Phone:714-887-7009
Mailing Address - Fax:714-968-4384
Practice Address - Street 1:17922 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708
Practice Address - Country:US
Practice Address - Phone:714-887-7009
Practice Address - Fax:714-968-4384
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26109111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC26109Medicare PIN
DC026109Medicare ID - Type Unspecified