Provider Demographics
NPI:1659730471
Name:IMPERIUM GROUP LLC
Entity Type:Organization
Organization Name:IMPERIUM GROUP LLC
Other - Org Name:CLINICA MEDICA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-390-7411
Mailing Address - Street 1:18037 FM 529 RD STE C
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77433-2243
Mailing Address - Country:US
Mailing Address - Phone:281-861-5180
Mailing Address - Fax:
Practice Address - Street 1:18037 FM 529 RD STE C
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77433-2243
Practice Address - Country:US
Practice Address - Phone:281-861-5180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IMPERIUM GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-02-22
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM43356207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty