=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710548003
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 2LA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2019
-----------------------------------------------------
Last Update Date | 06/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4354 US HIGHWAY 231 SUITE A
-----------------------------------------------------
City | WETUMPKA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-580-7061
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4049 US HIGHWAY 231 # 225
-----------------------------------------------------
City | WETUMPKA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36093-1217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-315-1183
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | MRS. MICHELLE K LANDREAU
-----------------------------------------------------
Credential | BC-HIS
-----------------------------------------------------
Telephone | 334-580-7061
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 237700000X
-----------------------------------------------------
Taxonomy Name | Hearing Instrument Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------