Basic Information
| Provider Information | |||||||||
| NPI: | 1871577759 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENNIS | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | KIMBERLY | ||||||||
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| Credential: | PT MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23100 EUCALYPTUS AVE STE C | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925535439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516604532 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 23100 EUCALYPTUS AVE STE C | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925535439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513791500 | ||||||||
| FaxNumber: | 9513791501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2005 | ||||||||
| LastUpdateDate: | 11/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT22506 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.