Basic Information
| Provider Information | |||||||||
| NPI: | 1053445189 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AUDIOLOGY CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 423 COLE SHOPPING CTR | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820015370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3074329601 | ||||||||
| FaxNumber: | 3074320411 | ||||||||
| Practice Location | |||||||||
| Address1: | 423 COLE SHOPPING CTR | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820015370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3074329601 | ||||||||
| FaxNumber: | 3074320411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2007 | ||||||||
| LastUpdateDate: | 07/15/2009 | ||||||||
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| AuthorizedOfficialLastName: | PIERSON | ||||||||
| AuthorizedOfficialFirstName: | JAN | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | AUDIOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 3074329601 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332S00000X | A-927 | WY | Y | Suppliers | Hearing Aid Equipment |
ID Information
| ID | Type | State | Issuer | Description | 109738501 | 05 | WY | MEDICAID |