Provider Demographics
NPI:1730715129
Name:MA, IM
Entity type:Individual
Prefix:
First Name:IM
Middle Name:
Last Name:MA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RINOA
Other - Middle Name:IM IENG
Other - Last Name:MA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2110 E FLAMINGO RD STE 350
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-5190
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2110 E FLAMINGO RD STE 150
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5190
Practice Address - Country:US
Practice Address - Phone:702-270-3219
Practice Address - Fax:866-833-2056
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-17
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician