Healthcare Provider Details

I. General information

NPI: 1003030115
Provider Name (Legal Business Name): SPOON RIVER HEARING SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 08/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 S MAIN ST
CANTON IL
61520-2608
US

IV. Provider business mailing address

811 W AVENUE H
LEWISTOWN IL
61542-8363
US

V. Phone/Fax

Practice location:
  • Phone: 309-647-0201
  • Fax: 309-649-8950
Mailing address:
  • Phone: 309-647-0201
  • Fax: 309-649-8950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number147000582
License Number StateIL

VIII. Authorized Official

Name: MRS. SANDI GREENE DEFORD
Title or Position: AUDIOLOGIST
Credential: M.S. CCC-A
Phone: 309-647-0201