Healthcare Provider Details

I. General information

NPI: 1760883573
Provider Name (Legal Business Name): STARBOARDTACK, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2014
Last Update Date: 09/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 W BAY AREA BLVD
WEBSTER TX
77598-4111
US

IV. Provider business mailing address

3005 BAYSHORE DR
BACLIFF TX
77518-1114
US

V. Phone/Fax

Practice location:
  • Phone: 821-332-1555
  • Fax: 405-603-2207
Mailing address:
  • Phone: 281-787-6367
  • Fax: 404-603-2207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License Number
License Number State

VIII. Authorized Official

Name: JAY LUTZ
Title or Position: OWNER
Credential:
Phone: 281-787-6367