Basic Information
| Provider Information | |||||||||
| NPI: | 1881827236 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHEAST HEARING LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | MIRACLE EAR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 131 ENTERPRISE RD | ||||||||
| Address2: | |||||||||
| City: | JOHNSTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120953326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013534174 | ||||||||
| FaxNumber: | 4014885774 | ||||||||
| Practice Location | |||||||||
| Address1: | 1241 S BROAD ST | ||||||||
| Address2: | |||||||||
| City: | WALLINGFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064921737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036307045 | ||||||||
| FaxNumber: | 2036301022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2009 | ||||||||
| LastUpdateDate: | 01/12/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FRASIER | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | HEARING INSTRUMENT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 2036307045 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332S00000X | 000393 | CT | N | Suppliers | Hearing Aid Equipment | 332S00000X | Y | Suppliers | Hearing Aid Equipment |
No ID Information.