1548480080 NPI number — MRS. VICKY MICHELLE WILLIS HEARING INSTURMENT S

Table of content: MRS. VICKY MICHELLE WILLIS HEARING INSTURMENT S (NPI 1548480080)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548480080 NPI number — MRS. VICKY MICHELLE WILLIS HEARING INSTURMENT S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIS
Provider First Name:
VICKY
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
HEARING INSTURMENT S
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCCOWEN
Provider Other First Name:
VICKY
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1548480080
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4121 SOUTH WATER TOWER PLACE, BELTONE HEARING
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT VERNON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62864
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-242-4901
Provider Business Mailing Address Fax Number:
618-242-2458

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4121 WATERTOWER PLACE
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62864-2347
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-242-4901
Provider Business Practice Location Address Fax Number:
618-242-2458
Provider Enumeration Date:
04/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 237700000X , with the licence number:  2254 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 237700000X , with the licence number: HIS2254 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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