Basic Information
Provider Information | |||||||||
NPI: | 1902228661 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTHLAND HEARING CENTERS, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PATTILLO BALANCE & HEARING CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2510 E SUNSET RD | ||||||||
Address2: | UNIT 5-260 | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891203511 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7027980113 | ||||||||
FaxNumber: | 8662915242 | ||||||||
Practice Location | |||||||||
Address1: | 4150 CARMICHAEL RD | ||||||||
Address2: | SUITE A-104 | ||||||||
City: | MONTGOMERY | ||||||||
State: | AL | ||||||||
PostalCode: | 361062932 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3342779480 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/15/2014 | ||||||||
LastUpdateDate: | 01/15/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LONGTAIN | ||||||||
AuthorizedOfficialFirstName: | JEFFREY | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5036595115 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |   |
No ID Information.