Healthcare Provider Details

I. General information

NPI: 1467521583
Provider Name (Legal Business Name): AUDIOLOGY AND HEARING AID CENTER OF GRESHAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 08/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

752 NE BURNSIDE ST
GRESHAM OR
97030
US

IV. Provider business mailing address

752 NE BURNSIDE ST
GRESHAM OR
97030
US

V. Phone/Fax

Practice location:
  • Phone: 503-669-7061
  • Fax: 503-492-3033
Mailing address:
  • Phone: 503-669-7061
  • Fax: 503-492-3033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number0310108088
License Number StateOR

VIII. Authorized Official

Name: MRS. SHERI L SMITH
Title or Position: AUDIOLOGIST
Credential: MS
Phone: 503-669-7061