Basic Information
| Provider Information | |||||||||
| NPI: | 1356670970 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIRACLE EAR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7171 N DAVIS HWY | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325046254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504745459 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1871 WELLS RD | ||||||||
| Address2: | UNIT 1 | ||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320732371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042695700 | ||||||||
| FaxNumber: | 9042699004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2009 | ||||||||
| LastUpdateDate: | 12/10/2009 | ||||||||
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| AuthorizedOfficialLastName: | CARLISLE | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
| AuthorizedOfficialMiddleName: | MARIA | ||||||||
| AuthorizedOfficialTitleorPosition: | PCC | ||||||||
| AuthorizedOfficialTelephone: | 8504745459 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0700X | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Hearing and Speech |
No ID Information.