Healthcare Provider Details

I. General information

NPI: 1821235888
Provider Name (Legal Business Name): REVELATION HEARING, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2009
Last Update Date: 01/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3050 N LAKE HARBOR LN STE 146
BOISE ID
83703-6354
US

IV. Provider business mailing address

3050 N LAKE HARBOR LN STE 146
BOISE ID
83703-6354
US

V. Phone/Fax

Practice location:
  • Phone: 208-343-2921
  • Fax: 208-854-1163
Mailing address:
  • Phone: 208-343-2921
  • Fax: 208-854-1163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHA-1017
License Number StateID

VIII. Authorized Official

Name: MS. JACQUELYN WOLF
Title or Position: PRESIDENT
Credential: BC-HIS
Phone: 208-861-3626