Basic Information
| Provider Information | |||||||||
| NPI: | 1740624667 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AUDIOLOGY DISTRIBUTION | ||||||||
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| OtherOrganizationName: | HEARUSA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10455 RIVERSIDE DR | ||||||||
| Address2: | |||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334104237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614788770 | ||||||||
| FaxNumber: | 5615987230 | ||||||||
| Practice Location | |||||||||
| Address1: | 6000 VENTURE DRIVE | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430172279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147641510 | ||||||||
| FaxNumber: | 6147642023 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2013 | ||||||||
| LastUpdateDate: | 04/22/2013 | ||||||||
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| AuthorizedOfficialLastName: | MORALES | ||||||||
| AuthorizedOfficialFirstName: | LILLIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTRACTING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5614788770 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 02443 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 0079935 | 05 | OH | MEDICAID |