Provider Demographics
NPI:1154978484
Name:PONTE VEDRA HEARING ASSOCIATES, LLC
Entity type:Organization
Organization Name:PONTE VEDRA HEARING ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HIS
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-373-5803
Mailing Address - Street 1:330 A1A N STE 325
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32082-1826
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:330 A1A N STE 325
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32082-1826
Practice Address - Country:US
Practice Address - Phone:904-373-5803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty