MEDICARE: IMD HEALTHCARE ASSOCIATION, INC.

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1427673375
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMD HEALTHCARE ASSOCIATION, INC.

Provider Business Mailing Address
First Line	:	1125 EXECUTIVE CIR STE 200
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75038-2522
Country	:	US
Telephone Number	:	817-522-2296
Fax Number	:

Provider Business Practice Location Address
First Line	:	5857 TORY DR
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-8500
Country	:	US
Telephone Number	:	817-522-2296
Fax Number	:

Authorized Official
Title or Position	:	OFFICER
Name	:	CHI VI LE CHAU
Credential	:
Telephone Number	:	817-522-2296

Provider Enumeration Date	:	06/16/2020
Last Update Date	:	06/16/2020

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