Healthcare Provider Details

I. General information

NPI: 1720280894
Provider Name (Legal Business Name): KENOSHA HEARING AID CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 06/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2527 75TH ST
KENOSHA WI
53143-1407
US

IV. Provider business mailing address

2527 75TH ST
KENOSHA WI
53143-1407
US

V. Phone/Fax

Practice location:
  • Phone: 262-654-4703
  • Fax: 262-654-4703
Mailing address:
  • Phone: 262-654-4703
  • Fax: 262-654-4703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License Number
License Number State

VIII. Authorized Official

Name: MR. KIM B PETERSON
Title or Position: PRESIDENT
Credential: HIS
Phone: 262-654-4703