Basic Information
| Provider Information | |||||||||
| NPI: | 1700119179 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PICKART HEARING SERVICE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 481 E DIVISION ST | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549353748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209261288 | ||||||||
| FaxNumber: | 9209260533 | ||||||||
| Practice Location | |||||||||
| Address1: | 481 E DIVISION ST | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549353748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209261288 | ||||||||
| FaxNumber: | 9209260533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2009 | ||||||||
| LastUpdateDate: | 09/16/2009 | ||||||||
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| AuthorizedOfficialLastName: | PICKART | ||||||||
| AuthorizedOfficialFirstName: | ANN | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9209261288 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | B.S.H.I.S. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | 42857500 | 05 | WI | MEDICAID |