Healthcare Provider Details

I. General information

NPI: 1407987522
Provider Name (Legal Business Name): S PANNU INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 06/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 SPRING RIDGE DR
SUSANVILLE CA
96130-6100
US

IV. Provider business mailing address

10624 S EASTERN AVE SUITE 263
HENDERSON NV
89052-2982
US

V. Phone/Fax

Practice location:
  • Phone: 530-252-2000
  • Fax:
Mailing address:
  • Phone: 702-597-1597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number8682
License Number StateNV

VIII. Authorized Official

Name: LORI A LABRECQUE
Title or Position: ACCTS. MGR
Credential:
Phone: 702-453-3799