1124183314 NPI number — EAST CENTRAL AUDIOLOGY, LTD

Table of content: (NPI 1124183314)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124183314 NPI number — EAST CENTRAL AUDIOLOGY, LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST CENTRAL AUDIOLOGY, LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124183314
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1068 LAKE ST S
Provider Second Line Business Mailing Address:
SUITE 108
Provider Business Mailing Address City Name:
FOREST LAKE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55025-2639
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-464-8486
Provider Business Mailing Address Fax Number:
651-464-8747

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1068 LAKE ST S
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
FOREST LAKE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55025-2639
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-464-8486
Provider Business Practice Location Address Fax Number:
651-464-8747
Provider Enumeration Date:
12/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PERREAULT
Authorized Official First Name:
JULIE
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
651-464-8486

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  6007 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 114370 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 41394 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1011302 . This is a "PERFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 5G979EA . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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