1063897874 NPI number — ADVANCE HEARING AID CENTER LLC

Table of content: (NPI 1063897874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063897874 NPI number — ADVANCE HEARING AID CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCE HEARING AID CENTER 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:
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:
1063897874
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1327 TOWNLINE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELOIT
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53511-4168
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-362-2669
Provider Business Mailing Address Fax Number:
608-362-2669

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1327 TOWNLINE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELOIT
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53511-4168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-362-2669
Provider Business Practice Location Address Fax Number:
608-362-2669
Provider Enumeration Date:
07/22/2015

Additional Information

Authorized Official

Authorized Official Last Name:
POTUZNIK
Authorized Official First Name:
SYNTHIA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OWNER HEARING INSTRUMENT SPECIALIST
Authorized Official Telephone Number:
608-362-2669

Provider Taxonomy Codes

  • Taxonomy code: 237700000X , with the licence number:  86460 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1174882245 . This is a "INDIVIDUAL NAME NPI NUMBER ASSIGNED" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 864 60 . This is a "CERTIFIED HEARING INSTRUMENT SPECIALIST" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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