Provider Demographics
NPI:1952721664
Name:BUSH, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BUSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1035
Mailing Address - Street 2:
Mailing Address - City:CENTER
Mailing Address - State:TX
Mailing Address - Zip Code:75935-1035
Mailing Address - Country:US
Mailing Address - Phone:936-590-4464
Mailing Address - Fax:936-590-4468
Practice Address - Street 1:3500 NORTH ST
Practice Address - Street 2:SUITE #1-A
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-2472
Practice Address - Country:US
Practice Address - Phone:936-569-8585
Practice Address - Fax:936-569-8525
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1001013332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies