Basic Information
Provider Information | |||||||||
NPI: | 1578684312 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MCCRAE MANAGEMENT & INVESTMENTS, LTD. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NEWSOUND HEARING AID CENTERS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 26222 RANCH ROAD 12 | ||||||||
Address2: |   | ||||||||
City: | DRIPPING SPRINGS | ||||||||
State: | TX | ||||||||
PostalCode: | 786204903 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5128580300 | ||||||||
FaxNumber: | 5128582714 | ||||||||
Practice Location | |||||||||
Address1: | 3506 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | VANCOUVER | ||||||||
State: | WA | ||||||||
PostalCode: | 98663 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3602602898 | ||||||||
FaxNumber: | 3606969517 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/02/2007 | ||||||||
LastUpdateDate: | 01/30/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DOMINEY | ||||||||
AuthorizedOfficialFirstName: | ELISE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING/CONTRACTING SPECIALIS | ||||||||
AuthorizedOfficialTelephone: | 5128580300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MCCRAE MANAGEMENT & INVESTMENTS, LTD. | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332S00000X |   |   | Y |   | Suppliers | Hearing Aid Equipment |   |
ID Information
ID | Type | State | Issuer | Description | 9178104 | 05 | WA |   | MEDICAID | 243241700 | 01 |   | OWCP | OTHER | 54627 | 01 | WA | WA LABOR & INDUSTRIES | OTHER | 212936 | 05 | OR |   | MEDICAID |