=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669611141
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GORDON RAY MITCHELL HIS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2009
-----------------------------------------------------
Last Update Date | 07/27/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1541 J.B.S PARKWAY #1
-----------------------------------------------------
City | ODESSA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-363-9566
-----------------------------------------------------
Fax | 432-362-0977
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5303 50TH STREET
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79414-5823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-799-8950
-----------------------------------------------------
Fax | 806-792-9404
-----------------------------------------------------
=====================================================
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 | 50621
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------