Provider Demographics
NPI:1295057503
Name:YBL PLLC
Entity type:Organization
Organization Name:YBL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:V
Authorized Official - Last Name:LIZAMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:1671-777-5259
Mailing Address - Street 1:643 CHALAN SAN ANTONIO
Mailing Address - Street 2:STE 109
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913-3644
Mailing Address - Country:US
Mailing Address - Phone:671-648-6390
Mailing Address - Fax:671-648-6398
Practice Address - Street 1:643 CHALAN SAN ANTONIO
Practice Address - Street 2:STE 109
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-3644
Practice Address - Country:US
Practice Address - Phone:671-648-6390
Practice Address - Fax:671-648-6398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-01
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUM0015192085U0001X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty