Provider Demographics
NPI:1437417409
Name:GRAND HEARING CENTER LLC
Entity Type:Organization
Organization Name:GRAND HEARING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUDIOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:LOGEL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MA
Authorized Official - Phone:517-647-4327
Mailing Address - Street 1:1330 E GRAND RIVER AVE
Mailing Address - Street 2:STE B
Mailing Address - City:PORTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48875-1630
Mailing Address - Country:US
Mailing Address - Phone:517-647-4327
Mailing Address - Fax:517-647-2442
Practice Address - Street 1:1330 E GRAND RIVER AVE
Practice Address - Street 2:STE B
Practice Address - City:PORTLAND
Practice Address - State:MI
Practice Address - Zip Code:48875-1630
Practice Address - Country:US
Practice Address - Phone:517-647-4327
Practice Address - Fax:517-647-2442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-27
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000414332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1285671164Medicaid
MI1285671164Medicare Oscar/Certification
MI1285671164Medicare PIN
1285671164Medicare NSC