# IMPERIAL MEDICINE LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1629504220
- **Authorized official:** DEANNA MOSSALLATI DO (MEMBER MANAGER)
- **Authorized official phone:** (318) 425-4096

## Contact information

- **Practice address:** 1800 IRVING PL, SHREVEPORT, LA 71101-4608
- **Practice address phone:** (318) 425-4096
- **Practice address fax:** (318) 425-8438
- **Mailing address:** PO BOX 64568, PHOENIX, AZ 85082-4568
- **Mailing address phone:** (318) 424-5449
- **Mailing address fax:** (855) 230-1466

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207R00000X | Internal Medicine Physician | 303623 | LA | Yes |

## Other

- **Enumeration date:** 05/03/2017
- **Last updated:** 05/03/2017