Provider Demographics
NPI:1316167620
Name:K J GORMAN, LLC
Entity type:Organization
Organization Name:K J GORMAN, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:AUD CCC A
Authorized Official - Phone:214-948-3273
Mailing Address - Street 1:267 WYNNEWOOD VILLAGE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75224
Mailing Address - Country:US
Mailing Address - Phone:214-948-3273
Mailing Address - Fax:214-942-4114
Practice Address - Street 1:267 WYNNEWOOD VILLAGE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75224
Practice Address - Country:US
Practice Address - Phone:214-948-3273
Practice Address - Fax:214-942-4114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-27
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX51598237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX80405AOtherINDIVIDUAL NUMBER
TX180691101Medicaid
TX0090MXOtherBLUE CROSS OF TEXAS GROUP
TX00718ZMedicare ID - Type UnspecifiedGROUP NUMBER
TX180691101Medicaid