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General NPI Number Information
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NPI Number | 1104237916
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Entity Type | Organization
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Legal Business Name | FORT WAYNE AUDIOLOGY CONSULTANTS, LLC
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Dates
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Enumeration Date | 05/14/2014
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Last Update Date | 04/27/2016
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Provider Practice Location Address
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Address Line | 4720 E STATE BLVD
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City | FORT WAYNE
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State | IN
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Zip | 46815-6923
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Country | US
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Telephone | 260-471-5693
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Fax | 260-471-4942
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Provider Business Mailing Address
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Address Line | 4720 E STATE BLVD
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City | FORT WAYNE
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State | IN
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Zip | 46815-6923
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Country | US
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Telephone | 260-471-5693
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Fax | 260-471-4942
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Authorized Official
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Title or Position | AUDIOLOGIST/OWNER
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Name | DR. THOMAS ZACHARY BURKLE
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Credential | AUD
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Telephone | 317-616-8048
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0700X
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Taxonomy Name | Hearing and Speech Clinic/Center
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License Number | 23002551A
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License Number State | IN
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