Healthcare Provider Details

I. General information

NPI: 1396208278
Provider Name (Legal Business Name): SHANE HOTTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5540 PGA BLVD
PALM BEACH GARDENS FL
33418-3987
US

IV. Provider business mailing address

5639 56TH WAY
WEST PALM BEACH FL
33409
US

V. Phone/Fax

Practice location:
  • Phone: 401-465-1863
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAS5431
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: