Healthcare Provider Details

I. General information

NPI: 1548468184
Provider Name (Legal Business Name): SUSAN L BURNS HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 10/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4331 E. MAIN ST. SUITE 202
FARMINGTON NM
87402
US

IV. Provider business mailing address

6225 RITA ST
FARMINGTON NM
87401-8805
US

V. Phone/Fax

Practice location:
  • Phone: 505-325-4101
  • Fax: 505-327-7947
Mailing address:
  • Phone: 508-274-1746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number141
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: