Provider Demographics
NPI:1477720712
Name:SCHROEDER, GREG A
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:A
Last Name:SCHROEDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1239 POLE LINE RD E
Mailing Address - Street 2:STE314C
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6046
Mailing Address - Country:US
Mailing Address - Phone:208-733-0601
Mailing Address - Fax:208-733-0604
Practice Address - Street 1:1239 POLE LINE RD E
Practice Address - Street 2:STE314C
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6046
Practice Address - Country:US
Practice Address - Phone:208-733-0601
Practice Address - Fax:208-733-0604
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDHA-1556237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty