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General NPI Number Information
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NPI Number | 1861970436
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Entity Type | Individual
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Provider Name | IME MBANG LVN
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Gender | Male
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Dates
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Enumeration Date | 08/05/2018
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Last Update Date | 08/05/2018
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Provider Practice Location Address
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Address Line | 234 CONWAY DR
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City | SAN ANTONIO
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State | TX
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Zip | 78209-1716
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Country | US
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Telephone | 210-612-8318
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Fax |
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Provider Business Mailing Address
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Address Line | 3711 MEDICAL DR APT 1527
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City | SAN ANTONIO
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State | TX
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Zip | 78229-2289
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Country | US
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Telephone | 210-612-8318
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 164X00000X
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Taxonomy Name | Licensed Vocational Nurse
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License Number | 308469
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License Number State | TX
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