MEDICARE: NORTHLAND HEARING CENTERS, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332S00000X	Hearing Aid Equipment
2	261QH0700X	Hearing and Speech Clinic/Center

General Provider Information

NPI Number	:	1558710723
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHLAND HEARING CENTERS, INC

Provider Business Mailing Address
First Line	:	6700 WASHINGTON AVE S
Second Line	:
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55344-3405
Country	:	US
Telephone Number	:	800-328-8602
Fax Number	:

Provider Business Practice Location Address
First Line	:	401 W FAIRMONT PKWY STE E
Second Line	:
City	:	LA PORTE
State	:	TX
Zip	:	77571-6314
Country	:	US
Telephone Number	:	281-470-4722
Fax Number	:	281-470-4780

Authorized Official
Title or Position	:	DIRECTOR OF CREDENTIALING
Name	:	LOUISA EIFRIG RAUTH
Credential	:
Telephone Number	:	952-947-4983

Provider Enumeration Date	:	06/08/2016
Last Update Date	:	12/18/2018

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