Basic Information
| Provider Information | |||||||||
| NPI: | 1407987522 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | S PANNU INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10624 S EASTERN AVE | ||||||||
| Address2: | SUITE 263 | ||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890522982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025971597 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1800 SPRING RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | SUSANVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961306100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302522000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 06/01/2009 | ||||||||
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| AuthorizedOfficialLastName: | LABRECQUE | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | ACCTS. MGR | ||||||||
| AuthorizedOfficialTelephone: | 7024533799 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 8682 | NV | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | A56442 | 01 | CA | MEDICAL LIC | OTHER | 002018039 | 05 | NV | MEDICAID |