Basic Information
| Provider Information | |||||||||
| NPI: | 1538457791 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDERIET | ||||||||
| FirstName: | MIKE | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | BC-HIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 705 S. RESERVE ST. #B | ||||||||
| Address2: | (HEARING AID INSTITUTE OF MISSOULA) | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065435025 | ||||||||
| FaxNumber: | 4067216071 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 S. RESERVE ST. #B | ||||||||
| Address2: | (HEARING AID INSTITUTE OF MISSOULA) | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 59801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065435025 | ||||||||
| FaxNumber: | 4067216071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2011 | ||||||||
| LastUpdateDate: | 08/13/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | 235 | MT | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.