Provider Demographics
NPI:1871583948
Name:PROVENZA-TABAK, LISA M (DC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:PROVENZA-TABAK
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 1:3680 STARRS CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9514
Mailing Address - Country:US
Mailing Address - Phone:330-702-0500
Mailing Address - Fax:330-702-0575
Practice Address - Street 1:3680 STARRS CENTRE DR
Practice Address - Street 2:
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-9514
Practice Address - Country:US
Practice Address - Phone:330-702-0500
Practice Address - Fax:330-705-0575
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-28
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2661111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2062888Medicaid
OH341935351-00OtherBWC
OH2062888Medicaid
OHU69946Medicare UPIN