=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588917926
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KITSAP AUDIOLOGY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2012
-----------------------------------------------------
Last Update Date | 10/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3100 NW BUCKLIN HILL RD STE 103
-----------------------------------------------------
City | SILVERDALE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98383-8358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-692-6650
-----------------------------------------------------
Fax | 360-692-8581
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3100 NW BUCKLIN HILL RD STE 103
-----------------------------------------------------
City | SILVERDALE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98383-8358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-692-6650
-----------------------------------------------------
Fax | 360-692-8581
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ROBERT BECKEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 360-692-6650
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 237700000X
-----------------------------------------------------
Taxonomy Name | Hearing Instrument Specialist
-----------------------------------------------------
License Number | 2618
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------