=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215108147
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIRACLE EAR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2008
-----------------------------------------------------
Last Update Date | 07/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3001 MAPLEWOOD DR
-----------------------------------------------------
City | MAPLEWOOD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55109-1080
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-770-5873
-----------------------------------------------------
Fax | 651-747-0149
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12737 RIVERDALE BLVD NW
-----------------------------------------------------
City | COON RAPIDS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55448-1253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-421-1688
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | TIMOTHY V VOTAVA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 763-421-1688
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 237600000X
-----------------------------------------------------
Taxonomy Name | Audiologist-Hearing Aid Fitter
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------