Healthcare Provider Details

I. General information

NPI: 1104237916
Provider Name (Legal Business Name): FORT WAYNE AUDIOLOGY CONSULTANTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 04/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4720 E STATE BLVD
FORT WAYNE IN
46815-6923
US

IV. Provider business mailing address

4720 E STATE BLVD
FORT WAYNE IN
46815-6923
US

V. Phone/Fax

Practice location:
  • Phone: 260-471-5693
  • Fax: 260-471-4942
Mailing address:
  • Phone: 260-471-5693
  • Fax: 260-471-4942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number23002551A
License Number StateIN

VIII. Authorized Official

Name: DR. THOMAS ZACHARY BURKLE
Title or Position: AUDIOLOGIST/OWNER
Credential: AUD
Phone: 317-616-8048