Provider Demographics
NPI:1467521583
Name:AUDIOLOGY AND HEARING AID CENTER OF GRESHAM
Entity Type:Organization
Organization Name:AUDIOLOGY AND HEARING AID CENTER OF GRESHAM
Other - Org Name:AUDIOLOGY AND HEARING AID CENTER OF GRESHAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUDIOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERI
Authorized Official - Middle Name:L
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:503-669-7061
Mailing Address - Street 1:752 NE BURNSIDE ST
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030
Mailing Address - Country:US
Mailing Address - Phone:503-669-7061
Mailing Address - Fax:503-492-3033
Practice Address - Street 1:752 NE BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030
Practice Address - Country:US
Practice Address - Phone:503-669-7061
Practice Address - Fax:503-492-3033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0310108088231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR182446Medicaid