Healthcare Provider Details

I. General information

NPI: 1902043185
Provider Name (Legal Business Name): EAR NOSE THROAT AND AUDIOLOGY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2009
Last Update Date: 01/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 W SOUTH ST
UNION SC
29379-2838
US

IV. Provider business mailing address

8318 PINEVILLE MATTHEWS RD SUITE 708-151
CHARLOTTE NC
28226-4753
US

V. Phone/Fax

Practice location:
  • Phone: 864-429-0115
  • Fax: 864-429-0271
Mailing address:
  • Phone: 704-544-6533
  • Fax: 704-544-6583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number
License Number State

VIII. Authorized Official

Name: LEROY BROADNAX
Title or Position: OFFICE MANAGER
Credential:
Phone: 704-544-6533