Healthcare Provider Details

I. General information

NPI: 1417358557
Provider Name (Legal Business Name): PORT TACK, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2014
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1195 ROUTE 70 UNIT 1007
LAKEWOOD NJ
08701-5946
US

IV. Provider business mailing address

PO BOX 1156
KEMAH TX
77565-1156
US

V. Phone/Fax

Practice location:
  • Phone: 732-994-7550
  • Fax:
Mailing address:
  • Phone: 281-787-6367
  • Fax: 405-603-2207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License Number
License Number State

VIII. Authorized Official

Name: JAY LUTZ
Title or Position: OWNER
Credential:
Phone: 281-787-6367