Healthcare Provider Details

I. General information

NPI: 1710156138
Provider Name (Legal Business Name): WYOMING HEARING CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/29/2008
Last Update Date: 02/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5320 EDUCATION DR
CHEYENNE WY
82009-4058
US

IV. Provider business mailing address

5320 EDUCATION DR
CHEYENNE WY
82009-4058
US

V. Phone/Fax

Practice location:
  • Phone: 307-632-8224
  • Fax: 307-635-3691
Mailing address:
  • Phone: 307-632-8224
  • Fax: 307-635-3691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License NumberA-954
License Number StateWY

VIII. Authorized Official

Name: MR. JONATHAN M ROSS
Title or Position: OWNER/AUDIOLOGIST
Credential: MS CCC-A
Phone: 307-632-8224