1548516354 NPI number — PATRIOT CENTER FOR HEARING LOSS & RELATED DISORDERS, LLC

Table of content: (NPI 1548516354)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548516354 NPI number — PATRIOT CENTER FOR HEARING LOSS & RELATED DISORDERS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATRIOT CENTER FOR HEARING LOSS & RELATED DISORDERS, 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:
6
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:
1548516354
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
661 E BROADWAY BLVD, STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JEFFERSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37760
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-471-0466
Provider Business Mailing Address Fax Number:
865-471-0468

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
661 E BROADWAY BLVD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
JEFFERSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37760
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-471-0466
Provider Business Practice Location Address Fax Number:
865-471-0468
Provider Enumeration Date:
07/30/2012

Additional Information

Authorized Official

Authorized Official Last Name:
STEPP
Authorized Official First Name:
TERESA
Authorized Official Middle Name:
Authorized Official Title or Position:
LLC MEMBER
Authorized Official Telephone Number:
865-471-0466

Provider Taxonomy Codes

  • Taxonomy code: 237600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QH0700X , with the licence number: 1162 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 231H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: Q046151 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4091430 . This is a "BLUECROSS BLUE SHIELD OF TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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