Provider Demographics
NPI:1124193347
Name:LOGAN AUDIOLOGY & HEARING AID CENTER INC
Entity Type:Organization
Organization Name:LOGAN AUDIOLOGY & HEARING AID CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:VERNON
Authorized Official - Middle Name:N
Authorized Official - Last Name:MULLINS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:304-752-6018
Mailing Address - Street 1:301 STRATTON STREET
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-3511
Mailing Address - Country:US
Mailing Address - Phone:304-752-6018
Mailing Address - Fax:304-752-4805
Practice Address - Street 1:301 STRATTON STREET
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3511
Practice Address - Country:US
Practice Address - Phone:304-752-6018
Practice Address - Fax:304-752-4805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWVA005231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0160758000Medicaid
WV0160758000Medicaid