=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831649334
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OREGON HEARING HEALTH SERVICE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2016
-----------------------------------------------------
Last Update Date | 07/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 90 MARKET ST STE 70
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97355-2395
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-258-6166
-----------------------------------------------------
Fax | 541-258-6166
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 90 MARKET ST STE 70
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97355-2395
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-258-6166
-----------------------------------------------------
Fax | 541-258-6166
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SAMUEL AARON MATHENY
-----------------------------------------------------
Credential | HAS-P
-----------------------------------------------------
Telephone | 541-258-6166
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332S00000X
-----------------------------------------------------
Taxonomy Name | Hearing Aid Equipment
-----------------------------------------------------
License Number | HAS-P-165880
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------