Healthcare Provider Details

I. General information

NPI: 1932473402
Provider Name (Legal Business Name): NORTHWEST AUDIOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2012
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 LACY ST NW
MARIETTA GA
30060-1107
US

IV. Provider business mailing address

80 LACY ST NW
MARIETTA GA
30060-1107
US

V. Phone/Fax

Practice location:
  • Phone: 770-427-0368
  • Fax: 678-581-5969
Mailing address:
  • Phone: 770-427-0368
  • Fax: 678-581-5969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License Number
License Number State

VIII. Authorized Official

Name: DEBBIE GOODMAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 770-427-0368