Healthcare Provider Details

I. General information

NPI: 1508988643
Provider Name (Legal Business Name): MR. MYRON LYLE BOURAY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 INWOOD VLG
DALLAS TX
75209-4393
US

IV. Provider business mailing address

333 INWOOD VLG
DALLAS TX
75209-4393
US

V. Phone/Fax

Practice location:
  • Phone: 214-750-1613
  • Fax: 214-635-5900
Mailing address:
  • Phone: 214-750-1613
  • Fax: 214-635-5900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number20262
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: