Healthcare Provider Details

I. General information

NPI: 1215297163
Provider Name (Legal Business Name): MODERN OTOACOUSTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2012
Last Update Date: 05/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 GLENDON ST
WOLFEBORO NH
03894-4481
US

IV. Provider business mailing address

PO BOX 1175
WOLFEBORO NH
03894-1175
US

V. Phone/Fax

Practice location:
  • Phone: 603-569-2799
  • Fax: 603-569-1815
Mailing address:
  • Phone: 603-569-2799
  • Fax: 603-569-1815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberH501
License Number StateNH

VIII. Authorized Official

Name: MS. JESSICA L WILLIAMS
Title or Position: OWNER
Credential: BC-HIS
Phone: 603-569-2799