MEDICARE: LEGACY AUDIOLOGY

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

General Provider Information

NPI Number	:	1699553578
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY AUDIOLOGY

Provider Business Mailing Address
First Line	:	1208 HILLTOP DR STE 105
Second Line	:
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-5858
Country	:	US
Telephone Number	:	307-522-5410
Fax Number	:

Provider Business Practice Location Address
First Line	:	1038 CYPRESS CIR
Second Line	:
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-4100
Country	:	US
Telephone Number	:	307-371-0789
Fax Number	:

Authorized Official
Title or Position	:	CO-OWER/ AUDIOLOGIST
Name	:	LIBBY MEHLE
Credential	:	AUD
Telephone Number	:	307-371-0789

Provider Enumeration Date	:	09/20/2023
Last Update Date	:	10/25/2023

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