Provider Demographics
NPI:1043304157
Name:SOUTHSIDE HEARING CENTER, LLC
Entity Type:Organization
Organization Name:SOUTHSIDE HEARING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF AUDIOLOGY
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:DEBRUYNE
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:585-243-7690
Mailing Address - Street 1:3513 THOMAS DR STE 2
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14480-9759
Mailing Address - Country:US
Mailing Address - Phone:585-243-7690
Mailing Address - Fax:
Practice Address - Street 1:3513 THOMAS DR STE 2
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:NY
Practice Address - Zip Code:14480-9759
Practice Address - Country:US
Practice Address - Phone:585-243-7690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
231H00000X
NY1451332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No332S00000XSuppliersHearing Aid EquipmentGroup - Multi-Specialty