Provider Demographics
NPI:1013252493
Name:360 AUDIO AND VISION
Entity Type:Organization
Organization Name:360 AUDIO AND VISION
Other - Org Name:HOUSTON TENS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:X-RAY TECH
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:COLLINS
Authorized Official - Last Name:FONTENOT
Authorized Official - Suffix:
Authorized Official - Credentials:LMRT
Authorized Official - Phone:832-715-2823
Mailing Address - Street 1:12400 SHADOW CREEK PKWY APT 1308
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7354
Mailing Address - Country:US
Mailing Address - Phone:832-715-2823
Mailing Address - Fax:
Practice Address - Street 1:12400 SHADOW CREEK PKWY APT 1308
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-7354
Practice Address - Country:US
Practice Address - Phone:832-715-2823
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX203281332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies