=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639345044
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WRIGHT'S HEARING AID CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2008
-----------------------------------------------------
Last Update Date | 05/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320 N ALPINE RD SUITE 105
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61107-4975
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-395-9567
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 320 N ALPINE RD SUITE 105
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61107-4975
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-395-9567
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. GARY RANDALL WRIGHT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 815-395-9567
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332S00000X
-----------------------------------------------------
Taxonomy Name | Hearing Aid Equipment
-----------------------------------------------------
License Number | 0887
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------