Provider Demographics
NPI:1740525278
Name:INTERNATIONAL HEALTH PROVIDERS, LLC
Entity type:Organization
Organization Name:INTERNATIONAL HEALTH PROVIDERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:CRISOSTOMO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:671-929-6214
Mailing Address - Street 1:655 HARMON LOOP RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:DEDEDO
Mailing Address - State:GU
Mailing Address - Zip Code:96929-6544
Mailing Address - Country:US
Mailing Address - Phone:671-929-6214
Mailing Address - Fax:
Practice Address - Street 1:655 HARMON LOOP RD
Practice Address - Street 2:SUITE 108
Practice Address - City:DEDEDO
Practice Address - State:GU
Practice Address - Zip Code:96929-6544
Practice Address - Country:US
Practice Address - Phone:671-929-6214
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-10
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty