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General NPI Number Information
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NPI Number | 1093131534
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Entity Type | Organization
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Legal Business Name | MICHAEL B. GILLIAM
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Dates
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Enumeration Date | 03/07/2014
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Last Update Date | 03/07/2014
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Provider Practice Location Address
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Address Line | 3101 KENNEDY LN SUITE 300
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City | TEXARKANA
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State | TX
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Zip | 75503-2457
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Country | US
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Telephone | 903-832-4327
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Fax | 903-831-2799
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Provider Business Mailing Address
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Address Line | 3101 KENNEDY LN SUITE 300
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City | TEXARKANA
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State | TX
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Zip | 75503-2457
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Country | US
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Telephone | 903-832-4327
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Fax | 903-831-2799
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Authorized Official
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Title or Position | OWNER, DISPENSER
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Name | MR. MICHAEL BRUCE GILLIAM
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Credential |
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Telephone | 903-832-4327
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332S00000X
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Taxonomy Name | Hearing Aid Equipment
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License Number |
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License Number State |
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