Healthcare Provider Details

I. General information

NPI: 1053196360
Provider Name (Legal Business Name): DOCTORS OF HEARING HEALTHCARE EAST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 08/28/2023
Certification Date: 08/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5063 SHORELINE RD
LAKE BARRINGTON IL
60010-1700
US

IV. Provider business mailing address

435 N MULFORD RD STE 10
ROCKFORD IL
61107-5100
US

V. Phone/Fax

Practice location:
  • Phone: 847-382-6010
  • Fax:
Mailing address:
  • Phone: 181-539-9527
  • Fax: 815-399-3764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code231HA2400X
TaxonomyAssistive Technology Practitioner Audiologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code231HA2500X
TaxonomyAssistive Technology Supplier Audiologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number
License Number State

VIII. Authorized Official

Name: BRYAN EARL TACKABERRY
Title or Position: OWNER
Credential:
Phone: 815-509-9898