Healthcare Provider Details

I. General information

NPI: 1467102046
Provider Name (Legal Business Name): MIKE LIM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2022
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2880 N TENAYA WAY FL 2
LAS VEGAS NV
89128-0618
US

IV. Provider business mailing address

2880 N TENAYA WAY FL 2
LAS VEGAS NV
89128-0618
US

V. Phone/Fax

Practice location:
  • Phone: 510-437-4965
  • Fax:
Mailing address:
  • Phone: 702-962-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberSL2041
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: