Basic Information
Provider Information | |||||||||
NPI: | 1447410436 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CASAS | ||||||||
FirstName: | GUSTAVO | ||||||||
MiddleName: | O | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 400 S HENDERSON ST | ||||||||
Address2: |   | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761041017 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8173352583 | ||||||||
FaxNumber: | 8173352597 | ||||||||
Practice Location | |||||||||
Address1: | 2295 NW LOOP | ||||||||
Address2: |   | ||||||||
City: | STEPHENVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 764011701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2549684174 | ||||||||
FaxNumber: | 2549686001 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/12/2008 | ||||||||
LastUpdateDate: | 06/12/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | 50122 | TX | Y |   | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |   |
No ID Information.