Provider Demographics
NPI:1699346494
Name:IMPERIALHEALTH CLINIC PLLC
Entity type:Organization
Organization Name:IMPERIALHEALTH CLINIC PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NP
Authorized Official - Prefix:
Authorized Official - First Name:TEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:OMOTAYO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-414-2615
Mailing Address - Street 1:1014 FERRIS AVE STE 108B
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-2599
Mailing Address - Country:US
Mailing Address - Phone:469-414-2615
Mailing Address - Fax:469-242-9743
Practice Address - Street 1:1014 FERRIS AVE STE 108B
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-2599
Practice Address - Country:US
Practice Address - Phone:469-414-2615
Practice Address - Fax:469-242-9743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-02
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)