Basic Information
| Provider Information | |||||||||
| NPI: | 1073746434 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BENJAMIN W. NORRIS INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MIRACLE EAR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 812 LAKE AIR DR | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767105745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547511100 | ||||||||
| FaxNumber: | 1877776167 | ||||||||
| Practice Location | |||||||||
| Address1: | 812 LAKE AIR DR | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767105745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547511100 | ||||||||
| FaxNumber: | 1877776167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2009 | ||||||||
| LastUpdateDate: | 09/01/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NORRIS | ||||||||
| AuthorizedOfficialFirstName: | BENJAMIN | ||||||||
| AuthorizedOfficialMiddleName: | WALTER | ||||||||
| AuthorizedOfficialTitleorPosition: | HEARING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 2547511100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | H.I.S. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332S00000X | 50235 | TX | Y | Suppliers | Hearing Aid Equipment |
ID Information
| ID | Type | State | Issuer | Description | 1528252459 | 01 | INDIVIDUAL NPI # | OTHER | 201942401 | 05 | TX | MEDICAID |