=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134481112
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH EAST GEORGIA HEARING & BALANCE CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2012
-----------------------------------------------------
Last Update Date | 06/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 355 CLEAR CREEK PKWY SUITE 201
-----------------------------------------------------
City | LAVONIA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30553-4173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-356-0377
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 355 CLEAR CREEK PKWY SUITE 201
-----------------------------------------------------
City | LAVONIA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30553-4173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-356-0377
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GEORGEANNE M THOMAS
-----------------------------------------------------
Credential | AUD
-----------------------------------------------------
Telephone | 706-621-0387
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | AUD001447
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------