=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912372418
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVADA AUDIOLOGY AND HEARING CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2015
-----------------------------------------------------
Last Update Date | 12/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 813 FOX LANE SUITE B
-----------------------------------------------------
City | WATERFORD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-514-4322
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 813 FOX LN
-----------------------------------------------------
City | WATERFORD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53185-4511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-514-4322
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HIS
-----------------------------------------------------
Name | MRS. LISA HAEUSER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 262-514-4322
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number | 143860
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------