Provider Demographics
NPI:1356800056
Name:LIZIMA, VILAIRE
Entity type:Individual
Prefix:
First Name:VILAIRE
Middle Name:
Last Name:LIZIMA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7525 DRAGON FLY LOOP
Mailing Address - Street 2:
Mailing Address - City:GIBSONTON
Mailing Address - State:FL
Mailing Address - Zip Code:33534-5648
Mailing Address - Country:US
Mailing Address - Phone:954-213-4855
Mailing Address - Fax:
Practice Address - Street 1:7525 DRAGON FLY LOOP
Practice Address - Street 2:
Practice Address - City:GIBSONTON
Practice Address - State:FL
Practice Address - Zip Code:33534-5648
Practice Address - Country:US
Practice Address - Phone:954-213-4855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL744398Medicaid