Provider Demographics
NPI:1316659006
Name:MELO, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MELO
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 1:5509 VOLKERTS RD
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-5937
Mailing Address - Country:US
Mailing Address - Phone:707-328-5832
Mailing Address - Fax:
Practice Address - Street 1:5509 VOLKERTS RD
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-5937
Practice Address - Country:US
Practice Address - Phone:707-328-5832
Practice Address - Fax:707-824-4434
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA490106870310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility