Healthcare Provider Details

I. General information

NPI: 1295057503
Provider Name (Legal Business Name): YBL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2010
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

643 CHALAN SAN ANTONIO STE 109
TAMUNING GU
96913-3644
US

IV. Provider business mailing address

643 CHALAN SAN ANTONIO STE 109
TAMUNING GU
96913-3644
US

V. Phone/Fax

Practice location:
  • Phone: 671-648-6390
  • Fax: 671-648-6398
Mailing address:
  • Phone: 671-648-6390
  • Fax: 671-648-6398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberM001519
License Number StateGU
# 2
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License NumberM001519
License Number StateGU

VIII. Authorized Official

Name: DR. VINCENT V LIZAMA
Title or Position: MANAGER
Credential: M.D.
Phone: 16717775259