Basic Information
| Provider Information | |||||||||
| NPI: | 1679750699 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GUNNISON HEARING CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 114 N BOULEVARD ST STE 106 | ||||||||
| Address2: | |||||||||
| City: | GUNNISON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812303011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706412814 | ||||||||
| FaxNumber: | 9702408823 | ||||||||
| Practice Location | |||||||||
| Address1: | 114 N BOULEVARD ST STE 106 | ||||||||
| Address2: | |||||||||
| City: | GUNNISON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812303011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706412814 | ||||||||
| FaxNumber: | 9702408823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2008 | ||||||||
| LastUpdateDate: | 01/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | HOUGHTON | ||||||||
| AuthorizedOfficialFirstName: | ELLYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9706412814 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MSCCC-A | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 38 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 34705775 | 05 | CO | MEDICAID |