=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538515721
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUDIONET AMERICA - ST CLAIR SHORES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2016
-----------------------------------------------------
Last Update Date | 11/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22631 GREATER MACK AVE SUITE 100
-----------------------------------------------------
City | SAINT CLAIR SHORES
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48080-2055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-252-2914
-----------------------------------------------------
Fax | 586-252-2918
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33900 HARPER AVE SUITE A101
-----------------------------------------------------
City | CLINTON TWP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48035-4258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-944-0043
-----------------------------------------------------
Fax | 586-261-5036
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. COLLEEN SHEFFERLY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 586-944-0043
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------