Healthcare Provider Details

I. General information

NPI: 1346365392
Provider Name (Legal Business Name): DWIGHT BRUCE DILLE HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

737 CAPE CORAL PKWY E
CAPE CORAL FL
33904
US

IV. Provider business mailing address

PO BOX 130
BARBOURSVILLE WV
25504
US

V. Phone/Fax

Practice location:
  • Phone: 239-542-0512
  • Fax:
Mailing address:
  • Phone: 304-523-3161
  • Fax: 304-523-5561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number680
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAS5095
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: