=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568550598
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RONALD JAMES CONLIN M.S. CCC-A
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 804 YELLOWSTONE AVE
-----------------------------------------------------
City | POCATELLO
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83201-4415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-232-3131
-----------------------------------------------------
Fax | 208-233-8351
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 804 YELLOWSTONE AVE
-----------------------------------------------------
City | POCATELLO
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83201-4415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-232-3131
-----------------------------------------------------
Fax | 208-233-8351
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 237600000X
-----------------------------------------------------
Taxonomy Name | Audiologist-Hearing Aid Fitter
-----------------------------------------------------
License Number | HA 384
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------