MEDICARE: IME MBANG LVN

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	164X00000X	Licensed Vocational Nurse	308469	TX

General Provider Information

NPI Number	:	1861970436
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IME MBANG LVN

Provider Business Mailing Address
First Line	:	3711 MEDICAL DR APT 1527
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-2289
Country	:	US
Telephone Number	:	210-612-8318
Fax Number	:

Provider Business Practice Location Address
First Line	:	234 CONWAY DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-1716
Country	:	US
Telephone Number	:	210-612-8318
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2018
Last Update Date	:	08/05/2018

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