MEDICARE: COOSA VALLEY HEARING CLINIC, INC

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	231H00000X	Audiologist	892A	AL

General Provider Information

NPI Number	:	1437464195
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COOSA VALLEY HEARING CLINIC, INC

Provider Business Mailing Address
First Line	:	208 W FORT WILLIAMS ST
Second Line	:
City	:	SYLACAUGA
State	:	AL
Zip	:	35150-2432
Country	:	US
Telephone Number	:	256-249-0943
Fax Number	:	256-249-0941

Provider Business Practice Location Address
First Line	:	208 W FORT WILLIAMS ST
Second Line	:
City	:	SYLACAUGA
State	:	AL
Zip	:	35150-2432
Country	:	US
Telephone Number	:	256-249-0943
Fax Number	:	256-249-0941

Authorized Official
Title or Position	:	AUDIOLOGIST, PRESIDENT
Name	:	MRS. STACEY D GRIMES
Credential	:	M.S.,CCC-A
Telephone Number	:	256-249-0943

Provider Enumeration Date	:	08/18/2010
Last Update Date	:	08/18/2010

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