Provider Demographics
NPI:1508047291
Name:LAKELAND PROFESSIONAL HEARING CENTER, INC.
Entity Type:Organization
Organization Name:LAKELAND PROFESSIONAL HEARING CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUDIOLOGIST/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHOWALTER
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:863-859-0754
Mailing Address - Street 1:5353 N SOCRUM LOOP RD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-4256
Mailing Address - Country:US
Mailing Address - Phone:863-859-0754
Mailing Address - Fax:863-859-4630
Practice Address - Street 1:5353 N SOCRUM LOOP RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-4256
Practice Address - Country:US
Practice Address - Phone:863-859-0754
Practice Address - Fax:863-859-4630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-21
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY1201231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS2917OtherBLUE CROSS BLUE SHIELD
FLK9672Medicare PIN