Basic Information
| Provider Information | |||||||||
| NPI: | 1144779380 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 5280 IOM PRO, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1651 | ||||||||
| Address2: | |||||||||
| City: | CROSBY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775321651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814627684 | ||||||||
| FaxNumber: | 8888325078 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 BASSETT ST UNIT 1021 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802021921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3462211597 | ||||||||
| FaxNumber: | 8325814677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2016 | ||||||||
| LastUpdateDate: | 09/29/2016 | ||||||||
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| AuthorizedOfficialLastName: | BISHOP | ||||||||
| AuthorizedOfficialFirstName: | JULIEANN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CO-OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3462211597 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0600X | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology |
No ID Information.