Basic Information
| Provider Information | |||||||||
| NPI: | 1720098536 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHN W. LOOPER JR. SPEECH & HEARING CLINIC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LOOPER SPEECH & HEARING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1011 PROFESSIONAL BLVD | ||||||||
| Address2: | |||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307202506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062264623 | ||||||||
| FaxNumber: | 7062780580 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 PROFESSIONAL BLVD | ||||||||
| Address2: | |||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307202506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062264623 | ||||||||
| FaxNumber: | 7062780580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 06/12/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EDWARDS | ||||||||
| AuthorizedOfficialFirstName: | KATHIE | ||||||||
| AuthorizedOfficialMiddleName: | LANE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 7062264623 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | J213493 | GA | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 235Z00000X | J213493 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 000196314A | 05 | GA | MEDICAID |