=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265769947
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUDIO VESTIBULAR ASSESSMENT, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2009
-----------------------------------------------------
Last Update Date | 03/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5344 PLAINFIELD AVE NE SUITE 4
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49525-1009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-365-1979
-----------------------------------------------------
Fax | 616-365-1964
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5344 PLAINFIELD AVE NE SUITE 4
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49525-1009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-365-1979
-----------------------------------------------------
Fax | 616-365-1964
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | MRS. KAREN ANN JACOBS
-----------------------------------------------------
Credential | AUD
-----------------------------------------------------
Telephone | 616-365-1979
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0700X
-----------------------------------------------------
Taxonomy Name | Hearing and Speech Clinic/Center
-----------------------------------------------------
License Number | KJ000001
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | KJ000001
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------