Provider Demographics
NPI:1790530467
Name:MIMWC,INC
Entity Type:Organization
Organization Name:MIMWC,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:B
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-621-1514
Mailing Address - Street 1:10089 WILLOW CREEK RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-1699
Mailing Address - Country:US
Mailing Address - Phone:858-621-1514
Mailing Address - Fax:
Practice Address - Street 1:625 KENMOOR AVE SE STE 350
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2395
Practice Address - Country:US
Practice Address - Phone:858-621-1514
Practice Address - Fax:858-585-4070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty