Basic Information
| Provider Information | |||||||||
| NPI: | 1235794330 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHLAND HEARING CENTERS, INC. | ||||||||
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| OtherOrganizationName: | NORTHLAND HEARING CENTERS, INC. DBA HEARING HEALTH CARE ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6700 WASHINGTON AVE S | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553443405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123511529 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1122 VETERANS DR STE 115 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626504032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172438951 | ||||||||
| FaxNumber: | 2176020489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2019 | ||||||||
| LastUpdateDate: | 05/29/2019 | ||||||||
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| AuthorizedOfficialLastName: | LAYTART | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | LEWIS | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 6123511529 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | Hearing and Speech |
No ID Information.