Healthcare Provider Details

I. General information

NPI: 1144779380
Provider Name (Legal Business Name): 5280 IOM PRO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2016
Last Update Date: 09/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 BASSETT ST UNIT 1021
DENVER CO
80202-1921
US

IV. Provider business mailing address

PO BOX 1651
CROSBY TX
77532-1651
US

V. Phone/Fax

Practice location:
  • Phone: 346-221-1597
  • Fax: 832-581-4677
Mailing address:
  • Phone: 281-462-7684
  • Fax: 888-832-5078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number StateCO

VIII. Authorized Official

Name: JULIEANN BISHOP
Title or Position: CO-OWNER
Credential:
Phone: 346-221-1597