1487847323 NPI number — MID-SOUTH HEARING, LLC

Table of content: (NPI 1487847323)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487847323 NPI number — MID-SOUTH HEARING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID-SOUTH HEARING, LLC
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:
MIRACLE-EAR HEARING AID CENTER
Provider Other Organization Name Type Code:
3
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:
1487847323
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
888 COUNTY ROAD 115
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW ALBANY
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38652-9518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-668-3165
Provider Business Mailing Address Fax Number:
731-668-9860

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2021 GREYSTONE SQ
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38305-3576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-668-3165
Provider Business Practice Location Address Fax Number:
731-668-9860
Provider Enumeration Date:
08/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HARDY
Authorized Official First Name:
BOBBY
Authorized Official Middle Name:
RICHARD
Authorized Official Title or Position:
OWNER/MANAGER
Authorized Official Telephone Number:
731-668-3165

Provider Taxonomy Codes

  • Taxonomy code: 237700000X , with the licence number:  658 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1B4080841 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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