Provider Demographics
NPI:1548564453
Name:WARREN PHUC THAI MD PC
Entity Type:Organization
Organization Name:WARREN PHUC THAI MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS MGR
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:LABRECQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-453-3799
Mailing Address - Street 1:PO BOX 33658
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89533-3658
Mailing Address - Country:US
Mailing Address - Phone:702-453-3799
Mailing Address - Fax:702-453-5741
Practice Address - Street 1:1800 SPRING RIDGE DR
Practice Address - Street 2:
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130-6100
Practice Address - Country:US
Practice Address - Phone:702-453-3799
Practice Address - Fax:702-453-5741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-06
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA108762208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV13174OtherNV LIC
CAA108762OtherCA LIC