Healthcare Provider Details

I. General information

NPI: 1558805770
Provider Name (Legal Business Name): SOUTHWEST HEARING CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2016
Last Update Date: 09/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 E SWALLOWTAIL LN
WASHINGTON UT
84780-2847
US

IV. Provider business mailing address

736 S 900 E SUITE 104
SAINT GEORGE UT
84790
US

V. Phone/Fax

Practice location:
  • Phone: 435-313-5556
  • Fax:
Mailing address:
  • Phone: 435-767-0240
  • Fax: 435-215-2535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number368331-4101
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number8245946-4601
License Number StateUT

VIII. Authorized Official

Name: JUSTIN DAVID BRADER
Title or Position: MANAGING MEMBER
Credential: BC-HIS
Phone: 435-313-5556