Healthcare Provider Details

I. General information

NPI: 1316178247
Provider Name (Legal Business Name): KYLE BAMBERG BC-HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2009
Last Update Date: 07/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 EUBANK BLVD NE STE 1
ALBUQUERQUE NM
87112-5300
US

IV. Provider business mailing address

1201 EUBANK BLVD NE STE 1
ALBUQUERQUE NM
87112-5300
US

V. Phone/Fax

Practice location:
  • Phone: 505-247-3277
  • Fax: 505-292-9467
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number0679
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: