MEDICARE: SANDIA HEARING SANTA FE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	237700000X	Hearing Instrument Specialist

General Provider Information

NPI Number	:	1063050383
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANDIA HEARING SANTA FE, LLC

Provider Business Mailing Address
First Line	:	3454 ZAFARANO DR STE B
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87507-2667
Country	:	US
Telephone Number	:	505-988-1984
Fax Number	:	503-474-3078

Provider Business Practice Location Address
First Line	:	3454 ZAFARANO DR STE B
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87507-2667
Country	:	US
Telephone Number	:	505-988-1984
Fax Number	:	503-474-3078

Authorized Official
Title or Position	:	OWNER / MANAGING MEMBER
Name	:	MR. JEFFREY L LONGTAIN
Credential	:
Telephone Number	:	503-799-2852

Provider Enumeration Date	:	12/17/2019
Last Update Date	:	12/17/2019

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