Provider Demographics
NPI:1003030115
Name:SPOON RIVER HEARING SERVICES INC
Entity Type:Organization
Organization Name:SPOON RIVER HEARING SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUDIOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDI
Authorized Official - Middle Name:GREENE
Authorized Official - Last Name:DEFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-A
Authorized Official - Phone:309-647-0201
Mailing Address - Street 1:811 W AVENUE H
Mailing Address - Street 2:
Mailing Address - City:LEWISTOWN
Mailing Address - State:IL
Mailing Address - Zip Code:61542-8363
Mailing Address - Country:US
Mailing Address - Phone:309-647-0201
Mailing Address - Fax:309-649-8950
Practice Address - Street 1:180 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2608
Practice Address - Country:US
Practice Address - Phone:309-647-0201
Practice Address - Fax:309-649-8950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147000582231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL35672291302Medicaid
IL35672291302Medicaid