Basic Information
| Provider Information | |||||||||
| NPI: | 1932305281 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHFORK SPEECH AND HEARING PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | FRONTIER AUDIOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 968 GILCHRIST ST | ||||||||
| Address2: | |||||||||
| City: | WHEATLAND | ||||||||
| State: | WY | ||||||||
| PostalCode: | 822012932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073223332 | ||||||||
| FaxNumber: | 3073223623 | ||||||||
| Practice Location | |||||||||
| Address1: | 968 GILCHRIST ST | ||||||||
| Address2: | |||||||||
| City: | WHEATLAND | ||||||||
| State: | WY | ||||||||
| PostalCode: | 822012932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073223332 | ||||||||
| FaxNumber: | 3073223623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2007 | ||||||||
| LastUpdateDate: | 01/30/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ARCHIE | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3073223332 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | AU.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 168 | NE | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 332S00000X | WY | N | Suppliers | Hearing Aid Equipment | 231H00000X | WY | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 237600000X | 627 | NE | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | 104704301 | 05 | WY | MEDICAID | 104704300 | 05 | WY | MEDICAID |