Provider Demographics
NPI:1154657351
Name:SOUTHERN IDAHO HEARING & AUDIOLOGY LLC
Entity Type:Organization
Organization Name:SOUTHERN IDAHO HEARING & AUDIOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:A
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:SEITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-324-4414
Mailing Address - Street 1:112 SEMINOLE CIR
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-6484
Mailing Address - Country:US
Mailing Address - Phone:208-324-4414
Mailing Address - Fax:
Practice Address - Street 1:1330 FILER AVE E
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4119
Practice Address - Country:US
Practice Address - Phone:208-734-4555
Practice Address - Fax:208-734-3632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-22
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAUD-1077231H00000X, 332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
No332S00000XSuppliersHearing Aid EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0000000Medicare UPIN