Basic Information
| Provider Information | |||||||||
| NPI: | 1992141147 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FONFARA | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | HAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2811 TAMIAMI TRL | ||||||||
| Address2: | STE.A | ||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339525173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9416298808 | ||||||||
| FaxNumber: | 9416291025 | ||||||||
| Practice Location | |||||||||
| Address1: | 2811 TAMIAMI TRL | ||||||||
| Address2: | STE.A | ||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339525173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9416298808 | ||||||||
| FaxNumber: | 9416291025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2013 | ||||||||
| LastUpdateDate: | 05/15/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | AS 3621 | FL | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.