Basic Information
| Provider Information | |||||||||
| NPI: | 1629561279 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LONG ISLAND QUEEN HEARING ASSO INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1953 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH BALDWIN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115102820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166233700 | ||||||||
| FaxNumber: | 6314993062 | ||||||||
| Practice Location | |||||||||
| Address1: | 1423 BEDFORD AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112163840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8554233700 | ||||||||
| FaxNumber: | 6314993062 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2018 | ||||||||
| LastUpdateDate: | 06/08/2018 | ||||||||
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| AuthorizedOfficialLastName: | ASHINOFF | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5166233700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332S00000X | 15000028517 | NY | Y | Suppliers | Hearing Aid Equipment |
ID Information
| ID | Type | State | Issuer | Description | 15000028517 | 01 | NY | NYS HEARING AID DISPENSER LICENSE | OTHER |