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General NPI Number Information
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NPI Number | 1326391749
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Entity Type | Organization
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Legal Business Name | IMPERIAL HEALTH LLP
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Dates
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Enumeration Date | 10/23/2012
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Last Update Date | 04/15/2013
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Provider Practice Location Address
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Address Line | 4150 NELSON RD SUITE E 1
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City | LAKE CHARLES
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State | LA
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Zip | 70605-4148
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Country | US
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Telephone | 337-433-8400
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Fax |
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Provider Business Mailing Address
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Address Line | 501 DR MICHAEL DEBAKEY DR
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City | LAKE CHARLES
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State | LA
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Zip | 70601-5724
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Country | US
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Telephone | 337-433-8400
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | KRIS HICKINGBOTTOM
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Credential |
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Telephone | 337-433-8400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 015309
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License Number State | LA
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