Basic Information
| Provider Information | |||||||||
| NPI: | 1679659403 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROANOKE VALLEY SPEECH AND HEARING CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2030 COLONIAL AVE. SW | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240153204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403430165 | ||||||||
| FaxNumber: | 5403454664 | ||||||||
| Practice Location | |||||||||
| Address1: | 2030 COLONIAL AVE. SW | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240153204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403430165 | ||||||||
| FaxNumber: | 5403454664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 04/14/2009 | ||||||||
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| AuthorizedOfficialLastName: | BROOKS | ||||||||
| AuthorizedOfficialFirstName: | J | ||||||||
| AuthorizedOfficialMiddleName: | ANDREE' | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5403430165 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | PHR | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 237600000X | 2101001443 | VA | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 231H00000X | 2201000601 | VA | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 0007926527 | 01 | VA | AETNA | OTHER | 0007768446 | 01 | VA | AETNA | OTHER | 7088632 | 01 | VA | AETNA | OTHER | 195182 | 01 | VA | ANTHEM | OTHER | 297809 | 01 | VA | MAMSI | OTHER | 0007790506 | 01 | VA | AETNA | OTHER | 004978331 | 05 | VA | MEDICAID | 010319544 | 05 | VA | MEDICAID | 282756 | 01 | VA | MAMSI | OTHER | 010197554 | 05 | VA | MEDICAID | 240052 | 01 | VA | MAMSI | OTHER | 384444 | 01 | VA | ANTHEM | OTHER | 240052 | 01 | VA | AETNA | OTHER |