Basic Information
| Provider Information | |||||||||
| NPI: | 1376848770 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHLAND HEARING CENTERS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | US HEARING CENTERS | ||||||||
| 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: | 6020 SAN JOSE BLVD | ||||||||
| Address2: | SUITE 615 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322172365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044254393 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2011 | ||||||||
| LastUpdateDate: | 12/29/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 04/22/2014 | ||||||||
| NPIReactivationDate: | 05/28/2014 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LONGTAIN | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7027980113 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTHLAND HEARING CENTERS INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 237700000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 237600000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
No ID Information.