=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700241627
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACEY OHL HIS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2015
-----------------------------------------------------
Last Update Date | 11/29/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12413 JUDSON RD STE 200
-----------------------------------------------------
City | LIVE OAK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78233-3215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-653-1722
-----------------------------------------------------
Fax | 210-653-1742
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8600 WURZBACH RD SUITE 500
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-593-9500
-----------------------------------------------------
Fax | 210-593-9504
-----------------------------------------------------
=====================================================
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 | 80667
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------