Healthcare Provider Details

I. General information

NPI: 1518177146
Provider Name (Legal Business Name): COWETA HEARING CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 12/17/2020
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 NEWNAN CROSSING BLVD E STE 160
NEWNAN GA
30265-2576
US

IV. Provider business mailing address

2301 NEWNAN CROSSING BLVD E STE 160
NEWNAN GA
30265-2576
US

V. Phone/Fax

Practice location:
  • Phone: 770-254-2224
  • Fax: 770-254-2225
Mailing address:
  • Phone: 770-254-2224
  • Fax: 770-254-2225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAUD003619
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License Number
License Number State

VIII. Authorized Official

Name: DR. NIKKI D WEAVER
Title or Position: OWNER
Credential:
Phone: 770-254-2224