Provider Demographics
NPI:1295002749
Name:AUDIO EAR HEARING CENTER
Entity Type:Organization
Organization Name:AUDIO EAR HEARING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEARING INSTRUMENT SPECIALIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DAREL
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-334-7700
Mailing Address - Street 1:65 S PLAZA WAY
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-5808
Mailing Address - Country:US
Mailing Address - Phone:573-334-7700
Mailing Address - Fax:573-334-7700
Practice Address - Street 1:65 S PLAZA WAY
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5808
Practice Address - Country:US
Practice Address - Phone:573-334-7700
Practice Address - Fax:573-334-7700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000748237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1124318258Medicaid
MO1124318258OtherTYPE 1-INDIVIDUAL NPI