Healthcare Provider Details

I. General information

NPI: 1770808834
Provider Name (Legal Business Name): REVIVE HEARING CENTERS OF INDIANA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2010
Last Update Date: 04/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9748 LANTERN RD
FISHERS IN
46037-9612
US

IV. Provider business mailing address

9748 LANTERN RD
FISHERS IN
46037-9612
US

V. Phone/Fax

Practice location:
  • Phone: 317-570-4401
  • Fax: 317-570-4403
Mailing address:
  • Phone: 317-570-4401
  • Fax: 317-570-4403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number23002010A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number23002010A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number17001288A
License Number StateIN

VIII. Authorized Official

Name: DR. JUDITH LYNNE HOWSER
Title or Position: MANAGER
Credential:
Phone: 317-570-4401