=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487258208
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMO SLEEP SOLUTIONS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2020
-----------------------------------------------------
Last Update Date | 11/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1641 LONGWOOD GLEN LN
-----------------------------------------------------
City | FRIENDSWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-404-9633
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1641 LONGWOOD GLEN LN
-----------------------------------------------------
City | FRIENDSWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-404-9633
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. KELVIN C IMO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 301-404-9633
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------