MEDICARE: YBL PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085U0001X	Diagnostic Ultrasound Physician	M001519	GU
2	2085R0202X	Diagnostic Radiology Physician	M001519	GU

General Provider Information

NPI Number	:	1295057503
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	YBL PLLC

Provider Business Mailing Address
First Line	:	643 CHALAN SAN ANTONIO
Second Line	:	STE 109
City	:	TAMUNING
State	:	GU
Zip	:	96913-3644
Country	:	US
Telephone Number	:	671-648-6390
Fax Number	:	671-648-6398

Provider Business Practice Location Address
First Line	:	643 CHALAN SAN ANTONIO
Second Line	:	STE 109
City	:	TAMUNING
State	:	GU
Zip	:	96913-3644
Country	:	US
Telephone Number	:	671-648-6390
Fax Number	:	671-648-6398

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. VINCENT V LIZAMA
Credential	:	M.D.
Telephone Number	:	16717775259

Provider Enumeration Date	:	03/01/2010
Last Update Date	:	09/15/2011

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