Healthcare Provider Details

I. General information

NPI: 1043304157
Provider Name (Legal Business Name): SOUTHSIDE HEARING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3513 THOMAS DR STE 2
LAKEVILLE NY
14480-9759
US

IV. Provider business mailing address

3513 THOMAS DR STE 2
LAKEVILLE NY
14480-9759
US

V. Phone/Fax

Practice location:
  • Phone: 585-243-7690
  • Fax: 585-346-7582
Mailing address:
  • Phone: 585-243-7690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License Number1451
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN BRADY
Title or Position: BUSINESS MANAGER
Credential:
Phone: 585-243-7690