Healthcare Provider Details

I. General information

NPI: 1790919496
Provider Name (Legal Business Name): ON-SITE AUDIOLOGY TX, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2009
Last Update Date: 05/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16095 PROSPERITY DR SUITE 300
NOBLESVILLE IN
46060-4319
US

IV. Provider business mailing address

16095 PROSPERITY DR STE. 300
NOBLESVILLE IN
46060-4319
US

V. Phone/Fax

Practice location:
  • Phone: 317-219-3456
  • Fax: 888-400-2221
Mailing address:
  • Phone: 371-219-3456
  • Fax: 888-400-2221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number17001256A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number17001256A
License Number StateIN

VIII. Authorized Official

Name: TERAH WAGNER
Title or Position: OWNER
Credential:
Phone: 317-443-0043