Basic Information
| Provider Information | |||||||||
| NPI: | 1275891962 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IDEALICS, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | THE HEARING PLACE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1301 11TH AVE S STE 4 | ||||||||
| Address2: | |||||||||
| City: | GREAT FALLS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 594054654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064522437 | ||||||||
| FaxNumber: | 4062165962 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 11TH AVE S STE 4 | ||||||||
| Address2: | |||||||||
| City: | GREAT FALLS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 594054654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064522437 | ||||||||
| FaxNumber: | 4062165962 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2012 | ||||||||
| LastUpdateDate: | 05/01/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FOURNIER | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 4064523247 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | BC-HIS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332S00000X | 225 | MT | Y | Suppliers | Hearing Aid Equipment |
No ID Information.