Provider Demographics
NPI:1447250931
Name:DEFOREST, LISA MARIE (DC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:DEFOREST
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41660 IVY ST STE B
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-9431
Mailing Address - Country:US
Mailing Address - Phone:951-696-9256
Mailing Address - Fax:951-696-0068
Practice Address - Street 1:41660 IVY ST STE B
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-9431
Practice Address - Country:US
Practice Address - Phone:951-696-9256
Practice Address - Fax:951-696-0068
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2024-11-04
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
CA24750111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA24750OtherSTATE LICENSE NUMBER
CA24750OtherSTATE LICENSE NUMBER
CADC0247500Medicare ID - Type Unspecified