Provider Demographics
NPI:1528391877
Name:REVIVE HEARING CENTER OF SAN MARCOS, LLC
Entity Type:Organization
Organization Name:REVIVE HEARING CENTER OF SAN MARCOS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:ETHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-360-1003
Mailing Address - Street 1:300 CM ALLEN PARKWAY
Mailing Address - Street 2:SUITE 300A
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666
Mailing Address - Country:US
Mailing Address - Phone:512-667-6904
Mailing Address - Fax:512-667-7138
Practice Address - Street 1:300 CM ALLEN PARKWAY
Practice Address - Street 2:SUITE 300A
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666
Practice Address - Country:US
Practice Address - Phone:512-667-6904
Practice Address - Fax:512-667-7138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-17
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32039416220332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment