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General NPI Number Information
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NPI Number | 1558805770
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Entity Type | Organization
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Legal Business Name | SOUTHWEST HEARING CLINIC LLC
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Dates
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Enumeration Date | 12/07/2016
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Last Update Date | 09/14/2017
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Provider Practice Location Address
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Address Line | 243 E SWALLOWTAIL LN
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City | WASHINGTON
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State | UT
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Zip | 84780-2847
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Country | US
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Telephone | 435-313-5556
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Fax |
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Provider Business Mailing Address
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Address Line | 736 S 900 E SUITE 104
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City | SAINT GEORGE
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State | UT
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Zip | 84790
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Country | US
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Telephone | 435-767-0240
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Fax | 435-215-2535
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | JUSTIN DAVID BRADER
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Credential | BC-HIS
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Telephone | 435-313-5556
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 237700000X
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Taxonomy Name | Hearing Instrument Specialist
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License Number | 8245946-4601
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 231H00000X
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Taxonomy Name | Audiologist
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License Number | 368331-4101
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License Number State | UT
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