Provider Demographics
NPI:1629504220
Name:IMPERIAL MEDICINE LLC
Entity Type:Organization
Organization Name:IMPERIAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSSALLATI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:318-425-4096
Mailing Address - Street 1:PO BOX 64568
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85082-4568
Mailing Address - Country:US
Mailing Address - Phone:318-424-5449
Mailing Address - Fax:855-230-1466
Practice Address - Street 1:1800 IRVING PL
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4608
Practice Address - Country:US
Practice Address - Phone:318-425-4096
Practice Address - Fax:318-425-8438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA303623207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty