=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215312897
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLEN HEARING ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2015
-----------------------------------------------------
Last Update Date | 09/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3373 PRINCETON RD SUITE D117
-----------------------------------------------------
City | HAMILTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45011-5416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-895-4327
-----------------------------------------------------
Fax | 513-894-4327
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1001 E. SUNSET ROAD UNIT 96595
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89193-1246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-798-0113
-----------------------------------------------------
Fax | 866-291-5242
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CHRISTOPHER A GLEN
-----------------------------------------------------
Credential | HAS
-----------------------------------------------------
Telephone | 513-895-4327
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 237600000X
-----------------------------------------------------
Taxonomy Name | Audiologist-Hearing Aid Fitter
-----------------------------------------------------
License Number | 03273
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 237700000X
-----------------------------------------------------
Taxonomy Name | Hearing Instrument Specialist
-----------------------------------------------------
License Number | 02225
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 332S00000X
-----------------------------------------------------
Taxonomy Name | Hearing Aid Equipment
-----------------------------------------------------
License Number | 03273
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------