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General NPI Number Information
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NPI Number | 1922540525
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Entity Type | Organization
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Legal Business Name | ACTIVEAR, LLC
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Dates
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Enumeration Date | 11/14/2016
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Last Update Date | 11/06/2023
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Provider Practice Location Address
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Address Line | 1601 US HIGHWAY 41 N
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City | TIFTON
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State | GA
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Zip | 31794-3205
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Country | US
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Telephone | 229-382-1996
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Fax | 229-245-1020
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Provider Business Mailing Address
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Address Line | 2935 N ASHLEY ST STE 101
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City | VALDOSTA
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State | GA
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Zip | 31602-1786
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Country | US
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Telephone | 229-245-1122
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Fax | 229-245-1020
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Authorized Official
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Title or Position | OWNER
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Name | MRS. LORISSA MILLER
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Credential |
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Telephone | 229-506-3451
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332S00000X
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Taxonomy Name | Hearing Aid Equipment
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License Number | HADE034972
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License Number State | GA
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