Basic Information
| Provider Information | |||||||||
| NPI: | 1902549637 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMMI, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2310 MARIANNE AVE | ||||||||
| Address2: | |||||||||
| City: | ZACHARY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707912740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856376629 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10101 PARK ROWE AVE | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708101686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257692200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2022 | ||||||||
| LastUpdateDate: | 04/20/2022 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | JESS | ||||||||
| AuthorizedOfficialMiddleName: | DUET | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 9856376629 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.