=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417078056
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BELTONE HEARING CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2007
-----------------------------------------------------
Last Update Date | 07/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 404 E BROAD ST STE 400
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76063-1749
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-453-8313
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 404 E BROAD ST STE 400
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76063-1749
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-453-8313
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | THERESA ZAHN-BURNAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-453-8313
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number | 50530
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------