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General NPI Number Information
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NPI Number | 1942501325
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Entity Type | Organization
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Legal Business Name | PHC OF BUFFALO GROVE AUDIOLOGY
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Dates
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Enumeration Date | 11/16/2010
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Last Update Date | 11/16/2010
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Provider Practice Location Address
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Address Line | 150 W HALF DAY RD SUITE 105
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City | BUFFALO GROVE
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State | IL
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Zip | 60089-6591
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Country | US
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Telephone | 847-868-3435
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Fax | 847-859-5885
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Provider Business Mailing Address
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Address Line | 150 W HALF DAY RD SUITE 105
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City | BUFFALO GROVE
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State | IL
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Zip | 60089-6591
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Country | US
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Telephone | 847-868-3435
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Fax | 847-859-5885
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHELLE MELISSA MATTINGLY
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Credential | AUD, CCC-A
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Telephone | 847-868-3435
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 237600000X
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Taxonomy Name | Audiologist-Hearing Aid Fitter
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License Number | 147-000978
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License Number State | IL
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