=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285218107
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENDEN WILLIAM MCCOY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2021
-----------------------------------------------------
Last Update Date | 05/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5129 DIXIE HWY STE 208
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40216-1727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-290-4798
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 131 ENTERPRISE RD
-----------------------------------------------------
City | JOHNSTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12095-3326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 237700000X
-----------------------------------------------------
Taxonomy Name | Hearing Instrument Specialist
-----------------------------------------------------
License Number | 269656
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------