MEDICARE: MALLORY VENTSAM ENTERPRISES, 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	332S00000X	Hearing Aid Equipment

General Provider Information

NPI Number	:	1437590965
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MALLORY VENTSAM ENTERPRISES, LLC

Provider Business Mailing Address
First Line	:	12627 PORTMARNOCK DR
Second Line	:
City	:	ODESSA
State	:	FL
Zip	:	33556-5416
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8125 STATE ROAD 52
Second Line	:
City	:	HUDSON
State	:	FL
Zip	:	34667-6728
Country	:	US
Telephone Number	:	727-378-8542
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MALLORY VENTSAM
Credential	:
Telephone Number	:	727-797-6500

Provider Enumeration Date	:	07/12/2013
Last Update Date	:	07/12/2013

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