Basic Information
Provider Information | |||||||||
NPI: | 1740301563 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WILLOUGHBY HEARING AID CENTERS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1939 E BURNSIDE ST | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972141535 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5032336141 | ||||||||
FaxNumber: | 5032332889 | ||||||||
Practice Location | |||||||||
Address1: | 1540 9TH AVE SE | ||||||||
Address2: |   | ||||||||
City: | ALBANY | ||||||||
State: | OR | ||||||||
PostalCode: | 973224869 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5419282182 | ||||||||
FaxNumber: | 5419282695 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/02/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MOULTON | ||||||||
AuthorizedOfficialFirstName: | CHRISTINE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | AUDIOLOGIST | ||||||||
AuthorizedOfficialTelephone: | 5032336141 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.S., CCC-A | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332S00000X |   |   | Y |   | Suppliers | Hearing Aid Equipment |   |
ID Information
ID | Type | State | Issuer | Description | 2432417000 | 01 |   | FEDERAL WORKERS' COMP | OTHER | 212936 | 05 | OR |   | MEDICAID |