Healthcare Provider Details

I. General information

NPI: 1760032205
Provider Name (Legal Business Name): TINA M ALLEN HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2019
Last Update Date: 09/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17650 WRIGHT ST STE 7
OMAHA NE
68130-2800
US

IV. Provider business mailing address

1708 S 162ND ST
OMAHA NE
68130-1410
US

V. Phone/Fax

Practice location:
  • Phone: 402-502-3115
  • Fax:
Mailing address:
  • Phone: 402-317-4186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number808
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: