=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588862775
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. CHARLENE MARJORIE MANTZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2007
-----------------------------------------------------
Last Update Date | 05/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5139 US HIGHWAY 19
-----------------------------------------------------
City | NEW PT RICHEY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34652-3966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-849-6076
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5139 US HIGHWAY 19
-----------------------------------------------------
City | NEW PT RICHEY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34652-3966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-849-6076
-----------------------------------------------------
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 | AS2621
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------