=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053584029
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALL EARS AUDIOLOGY OF ITHACA PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2008
-----------------------------------------------------
Last Update Date | 03/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 PLEASANT GROVE RD
-----------------------------------------------------
City | ITHACA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14850-2664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-257-3903
-----------------------------------------------------
Fax | 607-266-8821
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 PLEASANT GROVE RD
-----------------------------------------------------
City | ITHACA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14850-2664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-257-3903
-----------------------------------------------------
Fax | 607-266-8821
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUDIOLOGIST
-----------------------------------------------------
Name | MS. CAROL BASS
-----------------------------------------------------
Credential | M.S.
-----------------------------------------------------
Telephone | 607-257-3903
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332S00000X
-----------------------------------------------------
Taxonomy Name | Hearing Aid Equipment
-----------------------------------------------------
License Number | 15000000623
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | 000450
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------