Basic Information
| Provider Information | |||||||||
| NPI: | 1184677791 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHLAND HEARING CENTERS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2510 E SUNSET RD | ||||||||
| Address2: | UNIT 5-260 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 891203511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027980113 | ||||||||
| FaxNumber: | 8662915242 | ||||||||
| Practice Location | |||||||||
| Address1: | 1377 SPARTA CENTER DRIVE | ||||||||
| Address2: | |||||||||
| City: | SPARTA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184431918 | ||||||||
| FaxNumber: | 6184434278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 11/03/2017 | ||||||||
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| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF ADMIN OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 2812862999 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | 07900163001 | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 237700000X | 2005 | IL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 332S00000X | Y | Suppliers | Hearing Aid Equipment |
ID Information
| ID | Type | State | Issuer | Description | 2832016 | 01 | IL | BLUE CROSS BLUE SHIELD IL | OTHER |