Provider Demographics
NPI:1619596483
Name:LOUIS, LISBERTH N/A
Entity Type:Individual
Prefix:
First Name:LISBERTH
Middle Name:N/A
Last Name:LOUIS
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 1:629 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-3861
Mailing Address - Country:US
Mailing Address - Phone:804-615-1627
Mailing Address - Fax:
Practice Address - Street 1:629 HIGH ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-3861
Practice Address - Country:US
Practice Address - Phone:804-615-1627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-13
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)