Basic Information
| Provider Information | |||||||||
| NPI: | 1811240849 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRANGER | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | CLAUDE | ||||||||
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| Credential: | H.I.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6700 WASHINGTON AVE S | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553443405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123511529 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4301 SERGEANT RD STE 109 | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 51106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122932222 | ||||||||
| FaxNumber: | 7122932491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2012 | ||||||||
| LastUpdateDate: | 11/14/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | 765 | NE | N | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 237700000X | IA | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 237600000X | IA | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | 10025747800 | 05 | NE | MEDICAID |