MEDICARE: KOLTON CHASE BRUCE HIS

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	3497	IL

General Provider Information

NPI Number	:	1356067300
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KOLTON CHASE BRUCE HIS

Provider Business Mailing Address
First Line	:	700 N 54TH ST
Second Line	:
City	:	QUINCY
State	:	IL
Zip	:	62305-7909
Country	:	US
Telephone Number	:	217-640-5904
Fax Number	:

Provider Business Practice Location Address
First Line	:	700 N 54TH ST
Second Line	:
City	:	QUINCY
State	:	IL
Zip	:	62305-7909
Country	:	US
Telephone Number	:	217-640-5904
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2022
Last Update Date	:	04/06/2023

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