Healthcare Provider Details

I. General information

NPI: 1659578474
Provider Name (Legal Business Name): FAYETTEVILLE OTOLARYNGOLOGY HEAD AND NECK SURGERY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 01/12/2022
Certification Date: 01/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1839 QUIET CV
FAYETTEVILLE NC
28304-3857
US

IV. Provider business mailing address

1839 QUIET CV
FAYETTEVILLE NC
28304-3857
US

V. Phone/Fax

Practice location:
  • Phone: 910-323-1463
  • Fax: 910-323-1575
Mailing address:
  • Phone: 910-323-1463
  • Fax: 910-323-1575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number
License Number State

VIII. Authorized Official

Name: MRS. GWENDOLYN C PARKS
Title or Position: ADMINISTRATOR
Credential:
Phone: 910-323-1463