Provider Demographics
NPI:1154866671
Name:ALICE MAN CHAN, CCC-AUDIOLOGY, PC
Entity Type:Organization
Organization Name:ALICE MAN CHAN, CCC-AUDIOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:MAN
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:212-406-1968
Mailing Address - Street 1:202 SHORE RD
Mailing Address - Street 2:
Mailing Address - City:DOUGLASTON
Mailing Address - State:NY
Mailing Address - Zip Code:11363-1118
Mailing Address - Country:US
Mailing Address - Phone:718-353-5626
Mailing Address - Fax:
Practice Address - Street 1:139 CENTRE ST
Practice Address - Street 2:SUITE 803
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4552
Practice Address - Country:US
Practice Address - Phone:212-406-1968
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01690055Medicaid
NYM21701Medicare PIN
NY01690055Medicaid