Provider Demographics
NPI:1730676685
Name:SWEETIE PEETIE LLC
Entity Type:Organization
Organization Name:SWEETIE PEETIE LLC
Other - Org Name:FLAGLER HEARING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:VIRGIL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:BC-HIS
Authorized Official - Phone:904-553-8033
Mailing Address - Street 1:4750 E. MOODY BLVD
Mailing Address - Street 2:SUITE # 105
Mailing Address - City:BUNNELL
Mailing Address - State:FL
Mailing Address - Zip Code:32110-7710
Mailing Address - Country:US
Mailing Address - Phone:386-263-2833
Mailing Address - Fax:386-313-5134
Practice Address - Street 1:4750 E. MOODY BLVD
Practice Address - Street 2:SUITE # 105
Practice Address - City:BUNNELL
Practice Address - State:FL
Practice Address - Zip Code:32110-7710
Practice Address - Country:US
Practice Address - Phone:386-263-2833
Practice Address - Fax:386-313-5134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS2907237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty