Basic Information
| Provider Information | |||||||||
| NPI: | 1831404060 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JAG HOUSTON | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MIRACLE EAR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1533 W BAY AREA BLVD | ||||||||
| Address2: | |||||||||
| City: | WEBSTER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775983400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813382394 | ||||||||
| FaxNumber: | 2813161353 | ||||||||
| Practice Location | |||||||||
| Address1: | 1533 W BAY AREA BLVD | ||||||||
| Address2: | |||||||||
| City: | WEBSTER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775983400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813382394 | ||||||||
| FaxNumber: | 2813161353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2010 | ||||||||
| LastUpdateDate: | 08/12/2010 | ||||||||
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| AuthorizedOfficialLastName: | GUEST | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | JASON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4044447207 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | HADS000830 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.