Provider Demographics
NPI:1770023285
Name:CHOUKROUN, LISE
Entity Type:Individual
Prefix:
First Name:LISE
Middle Name:
Last Name:CHOUKROUN
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 1:78365 HIGHWAY 111 # 494
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-2071
Mailing Address - Country:US
Mailing Address - Phone:760-984-3426
Mailing Address - Fax:
Practice Address - Street 1:77682 COUNTRY CLUB DR STE G
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-0453
Practice Address - Country:US
Practice Address - Phone:760-984-3426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-02
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA71308225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist