=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912215765
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FANTL HEARING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2010
-----------------------------------------------------
Last Update Date | 09/15/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2642 EDGEWOOD RD.
-----------------------------------------------------
City | BEACHWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-896-0710
-----------------------------------------------------
Fax | 216-896-0711
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2642 EDGEWOOD DR.
-----------------------------------------------------
City | BEACHWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-896-0710
-----------------------------------------------------
Fax | 216-896-0711
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | MR. HAROLD I FANTL
-----------------------------------------------------
Credential | HEARING AID SPECIALI
-----------------------------------------------------
Telephone | 216-896-0711
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 237700000X
-----------------------------------------------------
Taxonomy Name | Hearing Instrument Specialist
-----------------------------------------------------
License Number | 02975
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------