Provider Demographics
NPI:1447391057
Name:LISA C. PREDMORE AU.D., PC
Entity Type:Organization
Organization Name:LISA C. PREDMORE AU.D., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:C
Authorized Official - Last Name:PREDMORE
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:516-627-7600
Mailing Address - Street 1:1165 NORTHERN BLVD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-3048
Mailing Address - Country:US
Mailing Address - Phone:516-627-7600
Mailing Address - Fax:516-627-6378
Practice Address - Street 1:1165 NORTHERN BLVD
Practice Address - Street 2:SUITE 302
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3048
Practice Address - Country:US
Practice Address - Phone:516-627-7600
Practice Address - Fax:516-627-6378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1204231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02266580Medicaid
NY02266580Medicaid
NY06641Medicare ID - Type UnspecifiedGHI MEDICARE