Basic Information
| Provider Information | |||||||||
| NPI: | 1740767763 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHLAND HEARING CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAMILY CARE HEARING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6700 WASHINGTON AVE S | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553443405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003288602 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 650 W TAYLOR ST | ||||||||
| Address2: | |||||||||
| City: | VANDALIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624711227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003288602 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2018 | ||||||||
| LastUpdateDate: | 07/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | XIONG | ||||||||
| AuthorizedOfficialFirstName: | BEE | ||||||||
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| AuthorizedOfficialTitleorPosition: | AR SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 9529956601 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332S00000X | N | Suppliers | Hearing Aid Equipment | 261QH0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | Hearing and Speech |
No ID Information.