Basic Information
| Provider Information | |||||||||
| NPI: | 1679583660 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCCRAE MANAGEMENT & INVESTMENT, LTD | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | NEWSOUND HEARING AID CENTERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 26222 RANCH ROAD 12 | ||||||||
| Address2: | |||||||||
| City: | DRIPPING SPRINGS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786204903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128585030 | ||||||||
| FaxNumber: | 5128582714 | ||||||||
| Practice Location | |||||||||
| Address1: | 1939 E BURNSIDE ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972141535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032336141 | ||||||||
| FaxNumber: | 5032332889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 01/30/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| 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 | 212936 | 05 | OR | MEDICAID | 243241700 | 01 | OWCP | OTHER | 54627 | 01 | WA | WA LABOR & INDUSTRIES | OTHER |