1689883654 NPI number — INTERNATIONAL MEDICAL ALLIANCE

Table of content: (NPI 1689883654)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689883654 NPI number — INTERNATIONAL MEDICAL ALLIANCE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERNATIONAL MEDICAL ALLIANCE
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:
Provider Other Organization Name Type Code:
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:
1689883654
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 15546
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95852-0546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-967-9300
Provider Business Mailing Address Fax Number:
916-967-9301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8653 DEERING BAY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89131-1757
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-967-9300
Provider Business Practice Location Address Fax Number:
916-967-9301
Provider Enumeration Date:
05/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DUNLEVY
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PHYSICIAN OWNER
Authorized Official Telephone Number:
916-967-9300

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  G61359 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X , with the licence number: 11845 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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