Healthcare Provider Details

I. General information

NPI: 1164475455
Provider Name (Legal Business Name): NORTHLAND HEARING CENTERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 10/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2419 W. BROADWAY
MT. VERNON IL
62864
US

IV. Provider business mailing address

2510 E SUNSET RD UNIT 5-260
LAS VEGAS NV
89120-3511
US

V. Phone/Fax

Practice location:
  • Phone: 618-241-9292
  • Fax: 618-242-1727
Mailing address:
  • Phone: 702-798-0113
  • Fax: 866-291-5242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2796
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number0410018001
License Number StateIL

VIII. Authorized Official

Name: JEFFREY L. LONGAIN
Title or Position: PRESIDENT
Credential:
Phone: 702-798-0113