Basic Information
| Provider Information | |||||||||
| NPI: | 1184943961 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | QUALITY OF LIFE HEARING SOLUTIONS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MIRACLE EAR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 581 STATE ROUTE 17M | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109503456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452385514 | ||||||||
| FaxNumber: | 8452385516 | ||||||||
| Practice Location | |||||||||
| Address1: | 96-05 QUEENS BLVD | ||||||||
| Address2: | SEARS MIRACLE EAR | ||||||||
| City: | REGO PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182755954 | ||||||||
| FaxNumber: | 7182755964 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2010 | ||||||||
| LastUpdateDate: | 05/19/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOCHTERLE | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8452385514 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | BC-HIS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | Hearing and Speech |
ID Information
| ID | Type | State | Issuer | Description | 15000018410 | 01 | NY | DEPARTMENT OF STATE DIVISION OF LICENSING SERVICES | OTHER |