# DR. LISA LICEAGA, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1447944830
- **Authorized official:** DR. LISA LICEAGA DO (PHYSICIAN)
- **Authorized official phone:** (949) 275-2718

## Contact information

- **Practice address:** 831 S STATE ROAD 434, ALTAMONTE SPRINGS, FL 32714-3502
- **Practice address phone:** (407) 587-8600
- **Mailing address:** 12386 STATE ROAD 535 \# 105, ORLANDO, FL 32836-6701
- **Mailing address phone:** (407) 801-3295
- **Mailing address fax:** (410) 907-7757

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QM2500X | Medical Specialty Clinic/Center | — | NULL | Yes |

## Other

- **Enumeration date:** 06/07/2023
- **Last updated:** 06/07/2023