Healthcare Provider Details

I. General information

NPI: 1770139198
Provider Name (Legal Business Name): REBECCA LYNN KLOSOWSKI HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BECKY LYNN KLOSOWSKI HIS

II. Dates (important events)

Enumeration Date: 08/12/2019
Last Update Date: 08/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 E LAMAR BLVD STE 624
ARLINGTON TX
76006-7346
US

IV. Provider business mailing address

1000 HENDERSON ST APT 346
FORT WORTH TX
76102-4567
US

V. Phone/Fax

Practice location:
  • Phone: 469-251-0577
  • Fax:
Mailing address:
  • Phone: 815-793-2103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number80582
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: