Healthcare Provider Details

I. General information

NPI: 1265769947
Provider Name (Legal Business Name): AUDIO VESTIBULAR ASSESSMENT, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2009
Last Update Date: 03/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5344 PLAINFIELD AVE NE SUITE 4
GRAND RAPIDS MI
49525-1009
US

IV. Provider business mailing address

5344 PLAINFIELD AVE NE SUITE 4
GRAND RAPIDS MI
49525-1009
US

V. Phone/Fax

Practice location:
  • Phone: 616-365-1979
  • Fax: 616-365-1964
Mailing address:
  • Phone: 616-365-1979
  • Fax: 616-365-1964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License NumberKJ000001
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberKJ000001
License Number StateMI

VIII. Authorized Official

Name: MRS. KAREN ANN JACOBS
Title or Position: OWNER/PRESIDENT
Credential: AUD
Phone: 616-365-1979