=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497092597
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MODERN HEARING SOLUTIONS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2013
-----------------------------------------------------
Last Update Date | 04/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2314 LINEVILLE RD SUITE 107
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54313-8860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-434-6800
-----------------------------------------------------
Fax | 920-434-7084
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2314 LINEVILLE RD SUITE 107
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54313-8860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-434-6800
-----------------------------------------------------
Fax | 920-434-7084
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR
-----------------------------------------------------
Name | CHAD R SORENSON
-----------------------------------------------------
Credential | B.S., H.I.S.
-----------------------------------------------------
Telephone | 920-434-6800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 237700000X
-----------------------------------------------------
Taxonomy Name | Hearing Instrument Specialist
-----------------------------------------------------
License Number | 1305-60
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------