Provider Demographics
NPI:1558805770
Name:SOUTHWEST HEARING CLINIC LLC
Entity Type:Organization
Organization Name:SOUTHWEST HEARING CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:BRADER
Authorized Official - Suffix:
Authorized Official - Credentials:BC-HIS
Authorized Official - Phone:435-313-5556
Mailing Address - Street 1:736 S 900 E
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790
Mailing Address - Country:US
Mailing Address - Phone:435-767-0240
Mailing Address - Fax:435-215-2535
Practice Address - Street 1:243 E SWALLOWTAIL LN
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:UT
Practice Address - Zip Code:84780-2847
Practice Address - Country:US
Practice Address - Phone:435-313-5556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-07
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT368331-4101231H00000X
UT8245946-4601237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty