Healthcare Provider Details

I. General information

NPI: 1720687890
Provider Name (Legal Business Name): PRAIRIE SEA HEARING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2020
Last Update Date: 12/10/2020
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 N 14TH ST STE 3C
BISMARCK ND
58503-0697
US

IV. Provider business mailing address

3000 N 14TH ST STE 3C
BISMARCK ND
58503-0697
US

V. Phone/Fax

Practice location:
  • Phone: 701-805-8057
  • Fax: 701-751-3168
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1477988459
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer
# 2
Identifier1790216844
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name: DR. JAY RAISEN
Title or Position: PHYSICIAN
Credential: MD
Phone: 701-805-8057