Basic Information
| Provider Information | |||||||||
| NPI: | 1306324405 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | METAMPA, LLC | ||||||||
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| OtherOrganizationName: | MIRACLE EAR CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204 WOODHEW DRIVE | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767126529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542275189 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6962 22ND AVE N | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337103920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273813277 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2018 | ||||||||
| LastUpdateDate: | 02/12/2019 | ||||||||
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| AuthorizedOfficialLastName: | KEY | ||||||||
| AuthorizedOfficialFirstName: | STEVE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 2542304149 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
No ID Information.