=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023300522
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHANDLER BEACH BC-HIS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2011
-----------------------------------------------------
Last Update Date | 12/11/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 N 37TH ST BLDG 3
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68701-3283
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-371-8295
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5224
-----------------------------------------------------
City | GRAND ISLAND
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68802-5224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-366-3489
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 237700000X
-----------------------------------------------------
Taxonomy Name | Hearing Instrument Specialist
-----------------------------------------------------
License Number | 730
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------