Healthcare Provider Details

I. General information

NPI: 1073047460
Provider Name (Legal Business Name): IMUS SLEEP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2017
Last Update Date: 04/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4022 E PRESIDIO ST
MESA AZ
85215-1113
US

IV. Provider business mailing address

PO BOX 20610
MESA AZ
85277-0610
US

V. Phone/Fax

Practice location:
  • Phone: 480-296-7642
  • Fax: 480-296-7643
Mailing address:
  • Phone: 480-296-7642
  • Fax: 480-296-7643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA0698
License Number StateAZ

VIII. Authorized Official

Name: FREDERICK SCOTT IMUS
Title or Position: SOLE MEMBER
Credential: CRNA
Phone: 480-570-9766