Basic Information
| Provider Information | |||||||||
| NPI: | 1669726204 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INDIANA HEARING LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MIRACLE EAR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 131 ENTERPRISE RD | ||||||||
| Address2: | |||||||||
| City: | JOHNSTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120953326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013534174 | ||||||||
| FaxNumber: | 4014885774 | ||||||||
| Practice Location | |||||||||
| Address1: | 715A S 42ND ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628646543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182422784 | ||||||||
| FaxNumber: | 6182422786 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2012 | ||||||||
| LastUpdateDate: | 05/03/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STEELE | ||||||||
| AuthorizedOfficialFirstName: | KAYLA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR CONTRACT NEGOTIATOR | ||||||||
| AuthorizedOfficialTelephone: | 5186204238 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332S00000X | Y | Suppliers | Hearing Aid Equipment |
No ID Information.