Provider Demographics
NPI:1023542511
Name:CENTRAL GEORGIA PROFESSIONAL HEARING SERVICES, LLC
Entity Type:Organization
Organization Name:CENTRAL GEORGIA PROFESSIONAL HEARING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUDIOLOGIST/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:SHEA
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:478-922-9222
Mailing Address - Street 1:1719 RUSSELL PKWY
Mailing Address - Street 2:BLDG 300
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-5763
Mailing Address - Country:US
Mailing Address - Phone:478-923-0106
Mailing Address - Fax:478-922-5211
Practice Address - Street 1:1719 RUSSELL PKWY
Practice Address - Street 2:BLDG 300
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-5763
Practice Address - Country:US
Practice Address - Phone:478-923-0106
Practice Address - Fax:478-922-5211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAUD003181231HA2400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA64PCBGFMedicare UPIN