Basic Information
| Provider Information | |||||||||
| NPI: | 1043621717 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROFESSIONAL HEARING CENTER, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DAILEY HEARING CENTER, PC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 E 23RD ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | FREMONT | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680252393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027218960 | ||||||||
| FaxNumber: | 4027217988 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 E 23RD ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | FREMONT | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680252393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027218960 | ||||||||
| FaxNumber: | 4027217988 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2014 | ||||||||
| LastUpdateDate: | 05/15/2014 | ||||||||
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| AuthorizedOfficialLastName: | DAILEY | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | AUDIOLOGIST/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4027218960 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | 112 | NE | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | NA2112 | 01 | NE | MEDICARE PTAN | OTHER |