MEDICARE: BLUE DRAGON ROGUES, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332S00000X	Hearing Aid Equipment

General Provider Information

NPI Number	:	1386068278
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE DRAGON ROGUES, INC

Provider Business Mailing Address
First Line	:	3305 S. MAYHILL ROAD
Second Line	:	SUITE 103
City	:	DENTON
State	:	TX
Zip	:	76208-6054
Country	:	US
Telephone Number	:	940-591-3028
Fax Number	:	940-591-3029

Provider Business Practice Location Address
First Line	:	3305 S MAYHILL RD
Second Line	:	103
City	:	DENTON
State	:	TX
Zip	:	76208-6053
Country	:	US
Telephone Number	:	940-591-3028
Fax Number	:	940-591-3029

Authorized Official
Title or Position	:	OWNER
Name	:	MR. DANIEL A PORTER
Credential	:
Telephone Number	:	940-591-3028

Provider Enumeration Date	:	02/12/2014
Last Update Date	:	02/12/2014

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