1659538411 NPI number — INTERNAL MEDICINE ASSOCIATES LABORATORY

Table of content: (NPI 1659538411)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659538411 NPI number — INTERNAL MEDICINE ASSOCIATES LABORATORY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERNAL MEDICINE ASSOCIATES LABORATORY
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:
1659538411
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6301 MOUNTAIN VISTA ST
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
HENDERSON
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89014-2364
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-792-4336
Provider Business Mailing Address Fax Number:
702-385-4823

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3121 S MARYLAND PKWY
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89109-2307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-369-1344
Provider Business Practice Location Address Fax Number:
702-369-6550
Provider Enumeration Date:
05/20/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BERMAN
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
ADMINISTRATION
Authorized Official Telephone Number:
702-464-7127

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  29D0538607 , 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)

  • Identifier: 100506353 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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