=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437410834
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTIN A MORTEMORE H.A.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2012
-----------------------------------------------------
Last Update Date | 07/30/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8006 IVYWOOD LN
-----------------------------------------------------
City | SYLVANIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-376-9860
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8006 IVYWOOD LN
-----------------------------------------------------
City | SYLVANIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43560-4212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-376-9860
-----------------------------------------------------
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 | 03000
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------