Provider Demographics
NPI:1760787550
Name:THAO, IMAIM NENG (PHD, LAC)
Entity Type:Individual
Prefix:DR
First Name:IMAIM
Middle Name:NENG
Last Name:THAO
Suffix:
Gender:M
Credentials:PHD, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15206 HASTINGS ST NE
Mailing Address - Street 2:
Mailing Address - City:HAM LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55304-6232
Mailing Address - Country:US
Mailing Address - Phone:763-208-6340
Mailing Address - Fax:763-208-6340
Practice Address - Street 1:1444 147TH AVE NE
Practice Address - Street 2:
Practice Address - City:HAM LAKE
Practice Address - State:MN
Practice Address - Zip Code:55304-4971
Practice Address - Country:US
Practice Address - Phone:763-208-6340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1324171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist