Healthcare Provider Details

I. General information

NPI: 1134419740
Provider Name (Legal Business Name): LG&H INTERNAL MEDICINE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2011
Last Update Date: 04/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

J&G COMMERCIAL PLAZA BLDG C SUITE 107
HAGATNA GU
96910
US

IV. Provider business mailing address

PO BOX 3268
HAGATNA GU
96932-3268
US

V. Phone/Fax

Practice location:
  • Phone: 671-475-5544
  • Fax: 671-475-5545
Mailing address:
  • Phone: 671-475-5544
  • Fax: 671-475-5545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM-1647
License Number StateGU

VIII. Authorized Official

Name: DR. RANDOLPH FLORES LEON GUERRERO
Title or Position: PHYSICIAN
Credential: MD
Phone: 671-475-5544