Basic Information
| Provider Information | |||||||||
| NPI: | 1164475455 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHLAND HEARING CENTERS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALL AMERICAN HEARING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2510 E SUNSET RD | ||||||||
| Address2: | UNIT 5-260 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891203511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027980113 | ||||||||
| FaxNumber: | 8662915242 | ||||||||
| Practice Location | |||||||||
| Address1: | 2419 W. BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MT. VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62864 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182419292 | ||||||||
| FaxNumber: | 6182421727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 10/01/2014 | ||||||||
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| AuthorizedOfficialLastName: | LONGAIN | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7027980113 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | 2796 | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 237600000X | 0410018001 | IL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | 2832016 | 01 | IL | BLUE CROSS BLUE SHIELD IL | OTHER |