Provider Demographics
NPI:1053473306
Name:UNITED HEALTH SERVICES OF ST. JOSEPH COUNTY, INC.
Entity Type:Organization
Organization Name:UNITED HEALTH SERVICES OF ST. JOSEPH COUNTY, INC.
Other - Org Name:HEARING AND SPEECH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BONITA
Authorized Official - Middle Name:A
Authorized Official - Last Name:RAINE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:574-247-6047
Mailing Address - Street 1:6910 N. MAIN ST. MAIL UNIT 10
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530
Mailing Address - Country:US
Mailing Address - Phone:574-247-6047
Mailing Address - Fax:574-247-6060
Practice Address - Street 1:6910 N MAIN ST UNIT 9
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-9681
Practice Address - Country:US
Practice Address - Phone:574-247-6047
Practice Address - Fax:574-247-6060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Not Answered237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
164230Medicare ID - Type Unspecified