Provider Demographics
NPI:1891892162
Name:INTERNATIONAL MERCANTILE ENTERPRISES
Entity Type:Organization
Organization Name:INTERNATIONAL MERCANTILE ENTERPRISES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CHACHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-996-0546
Mailing Address - Street 1:19323 COLLIER ST
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3010
Mailing Address - Country:US
Mailing Address - Phone:818-996-0546
Mailing Address - Fax:818-996-8624
Practice Address - Street 1:19323 COLLIER ST
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3010
Practice Address - Country:US
Practice Address - Phone:818-996-0546
Practice Address - Fax:818-996-8624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATG111Medicare PIN