Provider Demographics
NPI:1033410220
Name:IMPERIAL HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:IMPERIAL HEALTHCARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:R
Authorized Official - Last Name:BUCKLES
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:423-930-5168
Mailing Address - Street 1:1604 LAMONS LN STE 230
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-8224
Mailing Address - Country:US
Mailing Address - Phone:423-930-5168
Mailing Address - Fax:423-328-0193
Practice Address - Street 1:1604 LAMONS LN STE 230
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-8224
Practice Address - Country:US
Practice Address - Phone:423-930-5168
Practice Address - Fax:423-328-0193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000038183261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care