Healthcare Provider Details

I. General information

NPI: 1053787747
Provider Name (Legal Business Name): IM LOCUM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2015
Last Update Date: 08/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 S 2ND AVE
WALLA WALLA WA
99362-4116
US

IV. Provider business mailing address

1516 E TROPICANA AVE STE 155
LAS VEGAS NV
89119-8316
US

V. Phone/Fax

Practice location:
  • Phone: 702-453-3799
  • Fax: 702-453-5741
Mailing address:
  • Phone: 702-453-3799
  • Fax: 702-453-5741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD60475120
License Number StateWA

VIII. Authorized Official

Name: BRIAN NGUYEN
Title or Position: SOLE OWNER
Credential: M.D.
Phone: 714-230-5151