=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790815504
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FREMONT HEARING AID CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2007
-----------------------------------------------------
Last Update Date | 04/25/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2557 MOWRY AVE STE 31
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94538-1614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-651-0900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2557 MOWRY AVE SUITE 31
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94538-1603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-651-0900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. ERIN HEGLAND
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 510-651-0900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------