1194080606 NPI number — MIMI CHAN, LLC

Table of content: (NPI 1194080606)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194080606 NPI number — MIMI CHAN, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIMI CHAN, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NUTRITION COMFORT, LLC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194080606
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
515A SOUTH FRY ROAD
Provider Second Line Business Mailing Address:
SUITE 165
Provider Business Mailing Address City Name:
KATY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
515A SOUTH FRY ROAD
Provider Second Line Business Practice Location Address:
SUITE #165
Provider Business Practice Location Address City Name:
KATY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-916-2698
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/10/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CHAN
Authorized Official First Name:
MIMI
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
832-916-2698

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  DT83652 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6236760 . This is a "CIGNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 9050926 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".