Basic Information
| Provider Information | |||||||||
| NPI: | 1053787747 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IM LOCUM LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1516 E TROPICANA AVE STE 155 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891198316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024533799 | ||||||||
| FaxNumber: | 7024535741 | ||||||||
| Practice Location | |||||||||
| Address1: | 1025 S 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993624116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024533799 | ||||||||
| FaxNumber: | 7024535741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2015 | ||||||||
| LastUpdateDate: | 08/17/2015 | ||||||||
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| AuthorizedOfficialLastName: | NGUYEN | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | SOLE OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7142305151 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD60475120 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.