Provider Demographics
NPI:1194080606
Name:MIMI CHAN, LLC
Entity type:Organization
Organization Name:MIMI CHAN, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MIMI
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LD, CNSC, CDE
Authorized Official - Phone:832-916-2698
Mailing Address - Street 1:515A SOUTH FRY ROAD
Mailing Address - Street 2:SUITE 165
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:515A SOUTH FRY ROAD
Practice Address - Street 2:SUITE #165
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450
Practice Address - Country:US
Practice Address - Phone:832-916-2698
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-10
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT83652133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6236760OtherCIGNA
NY9050926OtherAETNA
NY9050926OtherAETNA