MEDICARE: IMIAH LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311Z00000X	Custodial Care Facility

General Provider Information

NPI Number	:	1770948176
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMIAH LLC

Provider Business Mailing Address
First Line	:	1855 WINDSOR DR
Second Line	:
City	:	LANCASTER
State	:	TX
Zip	:	75134-4148
Country	:	US
Telephone Number	:	469-236-4913
Fax Number	:	972-224-0088

Provider Business Practice Location Address
First Line	:	7520 MARIETTA LN
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75241-4422
Country	:	US
Telephone Number	:	469-236-4913
Fax Number	:	972-224-0088

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. SAPRINA DOVELL WINB
Credential	:
Telephone Number	:	469-236-4913

Provider Enumeration Date	:	12/29/2015
Last Update Date	:	12/03/2020

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Directions to “IMIAH LLC ” Practice Location

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