MEDICARE: IMAGINE NURTURING OUR WARRIORS, LTD

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1558833475
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMAGINE NURTURING OUR WARRIORS, LTD

Provider Business Mailing Address
First Line	:	7808 W BOULEVARD DR
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22308-1001
Country	:	US
Telephone Number	:	571-237-5403
Fax Number	:

Provider Business Practice Location Address
First Line	:	2500 PERLITER AVE
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89030-7309
Country	:	US
Telephone Number	:	571-237-5403
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BARRY MICHAEL MEUSE
Credential	:
Telephone Number	:	571-237-5403

Provider Enumeration Date	:	12/18/2018
Last Update Date	:	12/18/2018

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