=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356601967
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DESTIN HEARING SPECIALISTS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2012
-----------------------------------------------------
Last Update Date | 05/17/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 S HOLIDAY RD SUITE 400
-----------------------------------------------------
City | MIRAMAR BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32550-8606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-654-3373
-----------------------------------------------------
Fax | 850-654-3369
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 S HOLIDAY RD SUITE 400
-----------------------------------------------------
City | MIRAMAR BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32550-8606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-654-3373
-----------------------------------------------------
Fax | 850-654-3369
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SEAN M. MCWILLIAMS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 850-654-3373
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332S00000X
-----------------------------------------------------
Taxonomy Name | Hearing Aid Equipment
-----------------------------------------------------
License Number | L05000122403
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------