=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801656624
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYSON CASE HIS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2024
-----------------------------------------------------
Last Update Date | 03/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1970 E 17TH ST
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404-8014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-935-9487
-----------------------------------------------------
Fax | 208-542-1112
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1970 E 17TH ST
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404-8014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-935-9487
-----------------------------------------------------
Fax | 208-542-1112
-----------------------------------------------------
=====================================================
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 | HA-4152
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------