Basic Information
| Provider Information | |||||||||
| NPI: | 1174798789 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UTMB ECI LAUNCH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 UNIVERSITY BLVD | ||||||||
| Address2: | RT 1022 | ||||||||
| City: | GALVESTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775555302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097722222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 301 UNIVERSITY BLVD | ||||||||
| Address2: | RT 1022 | ||||||||
| City: | GALVESTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775555302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097722222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2008 | ||||||||
| LastUpdateDate: | 04/24/2008 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSOCIATE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4097727710 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UTMB FACULTY GROUP PRACTICE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 231H00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.