Basic Information
| Provider Information | |||||||||
| NPI: | 1578620092 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SANDIA MEDICAL INSTRUMENTS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SANDIA HEARING AIDS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10570 SE WASHINGTON ST | ||||||||
| Address2: | STE 210 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972162846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032576800 | ||||||||
| FaxNumber: | 8664486830 | ||||||||
| Practice Location | |||||||||
| Address1: | 3301 MENAUL BLVD NE | ||||||||
| Address2: | SUITE 26 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871071852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058899100 | ||||||||
| FaxNumber: | 5058880363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 10/21/2010 | ||||||||
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| AuthorizedOfficialLastName: | LONGTAIN | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5032576800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTHLAND HEARING CETNER, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | 330 | NM | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | T9008 | 05 | NM | MEDICAID |