MEDICARE: GENNETTE MARIE ERICKSON

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	HAD475	CO

General Provider Information

NPI Number	:	1508581570
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GENNETTE MARIE ERICKSON

Provider Business Mailing Address
First Line	:	190 TALISMAN DR UNIT C3
Second Line	:
City	:	PAGOSA SPGS
State	:	CO
Zip	:	81147-9171
Country	:	US
Telephone Number	:	970-731-4554
Fax Number	:	970-731-1868

Provider Business Practice Location Address
First Line	:	190 TALISMAN DR UNIT C3
Second Line	:
City	:	PAGOSA SPGS
State	:	CO
Zip	:	81147-9171
Country	:	US
Telephone Number	:	970-731-4554
Fax Number	:	970-731-1868

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

Provider Enumeration Date	:	10/11/2022
Last Update Date	:	10/11/2022

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