MEDICARE: EAR CLINIC, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0700X	Hearing and Speech Clinic/Center	309-156	WI

General Provider Information

NPI Number	:	1174806897
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAR CLINIC, LLC

Provider Business Mailing Address
First Line	:	125B E PINE ST
Second Line	:
City	:	LAKE MILLS
State	:	WI
Zip	:	53551-1103
Country	:	US
Telephone Number	:	920-648-4020
Fax Number	:	920-648-4365

Provider Business Practice Location Address
First Line	:	125B E PINE ST
Second Line	:
City	:	LAKE MILLS
State	:	WI
Zip	:	53551-1103
Country	:	US
Telephone Number	:	920-648-4020
Fax Number	:	920-648-4365

Authorized Official
Title or Position	:	AUDIOLOGIST
Name	:	DR. AMY K KROLL
Credential	:	AU.D.
Telephone Number	:	920-988-8223

Provider Enumeration Date	:	09/20/2011
Last Update Date	:	09/20/2011

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