=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841508173
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUDIOLOGY CONSULTANTS OF SOUTHWEST FLORIDA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2010
-----------------------------------------------------
Last Update Date | 07/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15721 NEW HAMPSHIRE CT
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-481-2088
-----------------------------------------------------
Fax | 239-481-2095
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15721 NEW HAMPSHIRE CT
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-481-2088
-----------------------------------------------------
Fax | 239-481-2095
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/AUDIOLOGIST
-----------------------------------------------------
Name | JACK (JOHN) H CHIPPENDALE
-----------------------------------------------------
Credential | CCC-A
-----------------------------------------------------
Telephone | 239-481-2088
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | AY274
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 237600000X
-----------------------------------------------------
Taxonomy Name | Audiologist-Hearing Aid Fitter
-----------------------------------------------------
License Number | AY274
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------