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General NPI Number Information
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NPI Number | 1003030115
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Entity Type | Organization
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Legal Business Name | SPOON RIVER HEARING SERVICES INC
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Dates
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Enumeration Date | 04/12/2007
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Last Update Date | 08/07/2014
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Provider Practice Location Address
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Address Line | 180 S MAIN ST
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City | CANTON
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State | IL
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Zip | 61520-2608
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Country | US
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Telephone | 309-647-0201
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Fax | 309-649-8950
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Provider Business Mailing Address
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Address Line | 811 W AVENUE H
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City | LEWISTOWN
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State | IL
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Zip | 61542-8363
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Country | US
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Telephone | 309-647-0201
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Fax | 309-649-8950
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Authorized Official
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Title or Position | AUDIOLOGIST
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Name | MRS. SANDI GREENE DEFORD
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Credential | M.S. CCC-A
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Telephone | 309-647-0201
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 231H00000X
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Taxonomy Name | Audiologist
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License Number | 147000582
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License Number State | IL
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