Provider Demographics
NPI:1528225596
Name:SYCAMORE HEARING AID CENTER
Entity Type:Organization
Organization Name:SYCAMORE HEARING AID CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROADDUS
Authorized Official - Suffix:
Authorized Official - Credentials:M S CCC A
Authorized Official - Phone:815-787-4237
Mailing Address - Street 1:2535 BETHANY ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178
Mailing Address - Country:US
Mailing Address - Phone:815-787-4327
Mailing Address - Fax:
Practice Address - Street 1:2535 BETHANY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3126
Practice Address - Country:US
Practice Address - Phone:815-787-4327
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147-000688261QH0700X, 332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No332S00000XSuppliersHearing Aid Equipment