Provider Demographics
NPI:1508152117
Name:REIMBOLD, EVAN A (HEARING INSTRUMENT D)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:A
Last Name:REIMBOLD
Suffix:
Gender:M
Credentials:HEARING INSTRUMENT D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1058
Mailing Address - Street 2:1717 W. MAIN STREET
Mailing Address - City:CARBENDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62903-1058
Mailing Address - Country:US
Mailing Address - Phone:618-457-6643
Mailing Address - Fax:618-457-6643
Practice Address - Street 1:1717 W. MAIN STREET
Practice Address - Street 2:
Practice Address - City:CARBENDALE
Practice Address - State:IL
Practice Address - Zip Code:62901
Practice Address - Country:US
Practice Address - Phone:618-457-6643
Practice Address - Fax:618-457-6643
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3009237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist