Basic Information
| Provider Information | |||||||||
| NPI: | 1649631102 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IRWIN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | CHID | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 E. SUNSET ROAD | ||||||||
| Address2: | UNIT 96595 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891931246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027980113 | ||||||||
| FaxNumber: | 8662915242 | ||||||||
| Practice Location | |||||||||
| Address1: | 15600 36TH AVE N | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554463369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635157575 | ||||||||
| FaxNumber: | 8552397375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2016 | ||||||||
| LastUpdateDate: | 03/11/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | 2416 | MN | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.