| Organization Name: | PARK PLACE DECLARANT |
| NPI Number: | 1487896114 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | SUZANNE KELLY (OWNER) |
| Mailing Address: | 2105 Mcculloch Blvd N #2 Lake Havasu City |
| State: | AZ US |
| Postal Code: | 864036772 |
| Phone Number: | 7028077931 |
| Fax Number: | 7023983757 |
| NPI Enumeration Date: | 03/26/2009 |
| NPI Last Update Date: | 03/26/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 332S00000X |
| License Number: | HAD5806 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | AZ |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Hearing Aid Equipment |
| Taxonomy Specialization: | |
| Taxonomy Definition: | The manufacture and/or sale of electronic hearing aids, their component parts, and related products and services on a national basis. |