1609274455 NPI number — AUDIOLOGICAL SERVICES OF CADILLAC

Table of content: (NPI 1609274455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609274455 NPI number — AUDIOLOGICAL SERVICES OF CADILLAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AUDIOLOGICAL SERVICES OF CADILLAC
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:
AUDIOLOGICAL SERVICES OF CADILLAC
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:
1609274455
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8872 PROFESSIONAL DR
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
CADILLAC
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49601-8481
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-779-6260
Provider Business Mailing Address Fax Number:
231-779-6264

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8872 PROFESSIONAL DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
CADILLAC
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49601-8481
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-779-6260
Provider Business Practice Location Address Fax Number:
231-779-6264
Provider Enumeration Date:
12/10/2014

Additional Information

Authorized Official

Authorized Official Last Name:
KENDELL
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
231-779-6260

Provider Taxonomy Codes

  • Taxonomy code: 207YX0905X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 237700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1548562978 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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