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General NPI Number Information
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NPI Number | 1457481491
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Entity Type | Individual
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Provider Name | ROGER FAIR CLEM CCC-A
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Gender | Male
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Dates
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Enumeration Date | 03/07/2007
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 140 BATTLEWOOD DR
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City | FORT OGLETHORPE
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State | GA
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Zip | 30742-4006
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Country | US
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Telephone | 706-861-7070
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Fax |
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Provider Business Mailing Address
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Address Line | 1606 LAKE MARINA DR
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City | HIXSON
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State | TN
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Zip | 37343-4661
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Country | US
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Telephone | 423-877-5570
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 231H00000X
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Taxonomy Name | Audiologist
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License Number | 3510
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License Number State | GA
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