Provider Demographics
NPI:1093131534
Name:MICHAEL B. GILLIAM
Entity Type:Organization
Organization Name:MICHAEL B. GILLIAM
Other - Org Name:MIKE GILLIAM HEARING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, DISPENSER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:GILLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-832-4327
Mailing Address - Street 1:3101 KENNEDY LN
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-2457
Mailing Address - Country:US
Mailing Address - Phone:903-832-4327
Mailing Address - Fax:903-831-2799
Practice Address - Street 1:3101 KENNEDY LN
Practice Address - Street 2:SUITE 300
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2457
Practice Address - Country:US
Practice Address - Phone:903-832-4327
Practice Address - Fax:903-831-2799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-07
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment