Healthcare Provider Details

I. General information

NPI: 1720425523
Provider Name (Legal Business Name): HEARING AID STORE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2013
Last Update Date: 06/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8400 MENAUL BLVD NE SUITE F
ALBUQUERQUE NM
87112-2260
US

IV. Provider business mailing address

8400 MENAUL BLVD NE SUITE F
ALBUQUERQUE NM
87112-2260
US

V. Phone/Fax

Practice location:
  • Phone: 505-299-7777
  • Fax: 505-299-7777
Mailing address:
  • Phone: 505-299-7777
  • Fax: 505-299-7777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number0832
License Number StateNM

VIII. Authorized Official

Name: JIMMY BURT BLAGG
Title or Position: PRESIDENT
Credential: HIS, HAD
Phone: 505-299-7777