=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851517528
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAR,NOSE,THROAT &ALLERGY ASSOCIATES PS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104 27TH AVE SE
-----------------------------------------------------
City | PUYALLUP
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98374-1145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-770-4099
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 104 27TH AVE SE
-----------------------------------------------------
City | PUYALLUP
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98374-1145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-770-4099
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RANDALL BENNETT
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 253-770-4099
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 237600000X
-----------------------------------------------------
Taxonomy Name | Audiologist-Hearing Aid Fitter
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------