Healthcare Provider Details

I. General information

NPI: 1336630342
Provider Name (Legal Business Name): SBS IOM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2018
Last Update Date: 07/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 E NAPOLEON ST #226
SULPHUR LA
70663-3318
US

IV. Provider business mailing address

320 E NAPOLEON ST #226
SULPHUR LA
70663-3318
US

V. Phone/Fax

Practice location:
  • Phone: 504-215-8179
  • Fax:
Mailing address:
  • Phone: 504-215-8179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. LIZETTE MORIN
Title or Position: MDMS NPI COMPLIANCE OFFICE
Credential:
Phone: 210-598-2801