=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376266817
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GRACE ELLEN RAHTJEN HIS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2022
-----------------------------------------------------
Last Update Date | 09/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1112 S MAIN ST STE B
-----------------------------------------------------
City | BOERNE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78006-2812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-609-9056
-----------------------------------------------------
Fax | 830-893-0132
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 919 PRIVATE ROAD 1712
-----------------------------------------------------
City | MICO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78056-5571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-370-2777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 237700000X
-----------------------------------------------------
Taxonomy Name | Hearing Instrument Specialist
-----------------------------------------------------
License Number | 81000
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------