1598981524 NPI number — PRINCETON AUDIOLOGY CLINIC, INC.,

Table of content: (NPI 1598981524)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598981524 NPI number — PRINCETON AUDIOLOGY CLINIC, INC.,

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRINCETON AUDIOLOGY CLINIC, INC.,
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:
DBA BLUE RIDGE HEARING AND BALANCE CLINIC
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:
1598981524
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
508 NEW HOPE ROAD
Provider Second Line Business Mailing Address:
SUITE #19
Provider Business Mailing Address City Name:
PRINCETON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
24740-2272
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-487-2487
Provider Business Mailing Address Fax Number:
304-431-3367

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 STADIUM DRIVE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
BLUEFIELD
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
24701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-324-2954
Provider Business Practice Location Address Fax Number:
304-324-2955
Provider Enumeration Date:
04/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DESMOND
Authorized Official First Name:
ALAN
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
304-487-2487

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: CC375 . This is a "PALMETTO GBA RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3810002482 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: PR9319052 . This is a "MEDICARE PALMETTO GBA PTAN NUMBER" identifier . This identifiers is of the category "OTHER".




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