MEDICARE: PHOENIX HEARING

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	237700000X	Hearing Instrument Specialist	HA3375	WA

General Provider Information

NPI Number	:	1285924894
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX HEARING

Provider Business Mailing Address
First Line	:	6400 NE HIGHWAY 99
Second Line	:	#G167
City	:	VANCOUVER
State	:	WA
Zip	:	98665-8748
Country	:	US
Telephone Number	:	360-433-8136
Fax Number	:	360-567-0620

Provider Business Practice Location Address
First Line	:	2402 BROADWAY ST
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98663-3229
Country	:	US
Telephone Number	:	360-433-8136
Fax Number	:	360-567-0620

Authorized Official
Title or Position	:	SPECIALIST/ MANAGER
Name	:	MR. BARRY A JETER
Credential	:	NBC/HIS
Telephone Number	:	360-433-8136

Provider Enumeration Date	:	04/15/2011
Last Update Date	:	04/15/2011

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