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General NPI Number Information
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NPI Number | 1366632655
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Entity Type | Organization
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Legal Business Name | EAR NOSE THROAT & AUDIOLOGY ASSOCIATES
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Dates
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Enumeration Date | 08/01/2007
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Last Update Date | 08/14/2015
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Provider Practice Location Address
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Address Line | 744 ARDEN LN SUITE 200
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City | ROCK HILL
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State | SC
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Zip | 29732-2984
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Country | US
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Telephone | 803-328-3686
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Fax | 803-328-9889
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Provider Business Mailing Address
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Address Line | 8334 PINEVILLE MATTHEWS RD SUITE 103-151
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City | CHARLOTTE
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State | NC
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Zip | 28226-3774
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Country | US
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Telephone | 803-328-3686
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Fax | 803-328-9889
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MR. LEROY BROADNAX
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Credential |
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Telephone | 803-328-3686
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number |
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License Number State |
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