Organization
IMMUNE CO MEDICAL GROUP PA
Active
Other names
MoldCo
Organization subpart
No
Provider details
NPI number
Authorized official
ARIANA THACKER (AUTHORIZED OFFICIAL)
(512) 789-7580
Entity
Organization
Contact information
Practice address
2500 BRANDON WAY, ROSWELL, NM 88201-9799
(512) 789-7580
Mailing address
1000 BRICKELL AVE STE 715, MIAMI, FL 33131-3047
(512) 789-7580
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
—
—
363AM0700X
Medical Physician Assistant
—
—
363LF0000X
Family Nurse Practitioner
—
—
376K00000X
Nurse's Aide
—
—
Other
Enumeration date
09/27/2024
Last updated
09/27/2024
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