Provider Demographics
NPI:1508006701
Name:NORTHEAST SAN ANTONIO HEARING AND BALANCE,LLC
Entity Type:Organization
Organization Name:NORTHEAST SAN ANTONIO HEARING AND BALANCE,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:L
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-653-1722
Mailing Address - Street 1:12413 JUDSON RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-3202
Mailing Address - Country:US
Mailing Address - Phone:210-653-1722
Mailing Address - Fax:210-653-1742
Practice Address - Street 1:12413 JUDSON RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3202
Practice Address - Country:US
Practice Address - Phone:210-653-1722
Practice Address - Fax:210-653-1742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-27
Last Update Date:2009-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50555332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1761140Medicaid