Healthcare Provider Details

I. General information

NPI: 1265159545
Provider Name (Legal Business Name): GREAT LAKES BAY HEARING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 W WACKERLY ST
MIDLAND MI
48640-7367
US

IV. Provider business mailing address

112 W WACKERLY ST
MIDLAND MI
48640-7367
US

V. Phone/Fax

Practice location:
  • Phone: 989-486-1457
  • Fax: 989-486-1479
Mailing address:
  • Phone: 989-486-1457
  • Fax: 989-486-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State

VIII. Authorized Official

Name: STEVEN SCOTT
Title or Position: OWNER
Credential:
Phone: 989-486-1457