Provider Demographics
NPI:1245788769
Name:SAM'S CLUB HEARING CENTER
Entity Type:Organization
Organization Name:SAM'S CLUB HEARING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEARING PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:HIS
Authorized Official - Phone:608-287-3455
Mailing Address - Street 1:7050 WATTS RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1365
Mailing Address - Country:US
Mailing Address - Phone:608-287-3455
Mailing Address - Fax:
Practice Address - Street 1:7050 WATTS RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1365
Practice Address - Country:US
Practice Address - Phone:608-287-3455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAM'S CLUB
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1463-60237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty