Provider Demographics
NPI:1063176170
Name:ISA5417, LLC
Entity type:Organization
Organization Name:ISA5417, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BLANCA
Authorized Official - Middle Name:YURAIMA
Authorized Official - Last Name:CORRIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-249-4949
Mailing Address - Street 1:14439 NW MILITARY HWY STE 108-449
Mailing Address - Street 2:
Mailing Address - City:SHAVANO PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78231-1646
Mailing Address - Country:US
Mailing Address - Phone:210-249-4949
Mailing Address - Fax:210-249-4949
Practice Address - Street 1:154 E MYRTLE AVE STE 100
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-4850
Practice Address - Country:US
Practice Address - Phone:801-210-5050
Practice Address - Fax:801-210-5050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-25
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty