=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386068278
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE DRAGON ROGUES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2014
-----------------------------------------------------
Last Update Date | 02/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3305 S MAYHILL RD 103
-----------------------------------------------------
City | DENTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76208-6053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-591-3028
-----------------------------------------------------
Fax | 940-591-3029
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3305 S. MAYHILL ROAD SUITE 103
-----------------------------------------------------
City | DENTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76208-6054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-591-3028
-----------------------------------------------------
Fax | 940-591-3029
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. DANIEL A PORTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 940-591-3028
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332S00000X
-----------------------------------------------------
Taxonomy Name | Hearing Aid Equipment
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------