Healthcare Provider Details

I. General information

NPI: 1659523694
Provider Name (Legal Business Name): TETON HEARING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2008
Last Update Date: 10/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 SKI HILL RD.
DRIGGS ID
83422
US

IV. Provider business mailing address

P.O. BOX 692
DRIGGS ID
83422
US

V. Phone/Fax

Practice location:
  • Phone: 208-569-8787
  • Fax: 208-354-2656
Mailing address:
  • Phone: 208-569-8787
  • Fax: 208-354-2656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAUD1142
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberA-974
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberAUD1142
License Number StateID
# 4
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberA-974
License Number StateWY

VIII. Authorized Official

Name: ELIZA S. PETERSEN
Title or Position: MANAGER/MEMBER/AUDIOLOGIST
Credential: M.A. CCC-A FAAA
Phone: 208-569-8787