Provider Demographics
NPI:1962876847
Name:IM, JIMMY MACK
Entity type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:MACK
Last Name:IM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4938 N MUSCATEL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-2142
Mailing Address - Country:US
Mailing Address - Phone:626-228-9201
Mailing Address - Fax:
Practice Address - Street 1:4938 N MUSCATEL AVE
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-2142
Practice Address - Country:US
Practice Address - Phone:626-228-9201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA292252164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse