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	237600000X	Audiologist-Hearing Aid Fitter

General Provider Information

NPI Number	:	1609151802
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHLAND HEARING CENTERS, INC.

Provider Business Mailing Address
First Line	:	8800 SE SUNNYSIDE RD
Second Line	:	STE 300-N
City	:	CLACKAMAS
State	:	OR
Zip	:	97015-5738
Country	:	US
Telephone Number	:	503-659-5115
Fax Number	:

Provider Business Practice Location Address
First Line	:	6175 CAHILL AVE STE 103
Second Line	:
City	:	INVER GROVE HEIGHTS
State	:	MN
Zip	:	55076-1527
Country	:	US
Telephone Number	:	651-967-7760
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JEFFREY LONGTAIN
Credential	:
Telephone Number	:	503-659-5115

Provider Enumeration Date	:	10/19/2011
Last Update Date	:	10/19/2011

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