Healthcare Provider Details

I. General information

NPI: 1609682491
Provider Name (Legal Business Name): AUDACIOUS ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2024
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2823 SKERNE FOREST DR
SPRING TX
77373-2391
US

IV. Provider business mailing address

2823 SKERNE FOREST DR
SPRING TX
77373-2391
US

V. Phone/Fax

Practice location:
  • Phone: 832-250-5137
  • Fax:
Mailing address:
  • Phone: 832-250-5137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: ASIA RENISE MAYO
Title or Position: OWNER
Credential:
Phone: 832-250-5137