Provider Demographics
NPI:1073580817
Name:PRINCETON AUDIOLOGY CLINIC, INC.,
Entity Type:Organization
Organization Name:PRINCETON AUDIOLOGY CLINIC, INC.,
Other - Org Name:DBA BLUE RIDGE HEARING AND BALANCE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:DESMOND
Authorized Official - Suffix:
Authorized Official - Credentials:AUD, CCC-A
Authorized Official - Phone:304-487-2487
Mailing Address - Street 1:508 NEW HOPE ROAD
Mailing Address - Street 2:SUITE #19
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2272
Mailing Address - Country:US
Mailing Address - Phone:304-487-2487
Mailing Address - Fax:304-431-3367
Practice Address - Street 1:508 NEW HOPE ROAD
Practice Address - Street 2:SUITE #19
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2272
Practice Address - Country:US
Practice Address - Phone:304-487-2487
Practice Address - Fax:304-431-3367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-01
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332S00000XSuppliersHearing Aid Equipment
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CC3775OtherPALMETTO GBA RR MEDICARE
WV4250000-000Medicaid
WV4250000000Medicaid
PR9319052OtherPALMETTO GBA MEDICARE PTAN NUMBER BLFD OFFICE
WV3810002482Medicaid
PR9319051OtherPALMETTO GBA MEDICARE PTAN NUMBER PCTN OFFICE
WV4250000-000Medicaid
CC3775OtherPALMETTO GBA RR MEDICARE