Basic Information
| Provider Information | |||||||||
| NPI: | 1104124387 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REALEAR, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 PALM COAST PKWY SW | ||||||||
| Address2: | SUITE #109 | ||||||||
| City: | PALM COAST | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321374746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3864473530 | ||||||||
| FaxNumber: | 3864473633 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 PALM COAST PKWY SW | ||||||||
| Address2: | SUITE #109 | ||||||||
| City: | PALM COAST | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321374746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3864473530 | ||||||||
| FaxNumber: | 3864473633 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2011 | ||||||||
| LastUpdateDate: | 03/11/2011 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3864473530 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | BC-HAS-ACA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 237700000X | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.