MEDICARE: PALMETTO FAMILY HEARING CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0700X	Hearing and Speech Clinic/Center	5785	NC
2	261QH0700X	Hearing and Speech Clinic/Center	3913	SC

General Provider Information

NPI Number	:	1639563620
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALMETTO FAMILY HEARING CENTER, LLC

Provider Business Mailing Address
First Line	:	127 BEN CASEY DR.
Second Line	:	SUITE 105
City	:	FORT MILL
State	:	SC
Zip	:	29708-8557
Country	:	US
Telephone Number	:	803-547-4327
Fax Number	:	803-547-4329

Provider Business Practice Location Address
First Line	:	127 BEN CASEY DR.
Second Line	:	SUITE 105
City	:	FORT MILL
State	:	SC
Zip	:	29708-8557
Country	:	US
Telephone Number	:	803-547-4327
Fax Number	:	803-547-4329

Authorized Official
Title or Position	:	DOCTOR OF AUDIOLOGY/OWNER
Name	:	DR. GARY WAYNE FIKE JR.
Credential	:	AUD
Telephone Number	:	803-547-4327

Provider Enumeration Date	:	03/27/2015
Last Update Date	:	07/29/2015

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