Provider Demographics
NPI:1568706810
Name:GREAT LAKES AUDIOLOGY, LLC
Entity Type:Organization
Organization Name:GREAT LAKES AUDIOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/AUDIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:KEIFER
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:419-464-8915
Mailing Address - Street 1:3780 KING RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43617-1400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3780 KING RD
Practice Address - Street 2:SUITE C
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43617-1400
Practice Address - Country:US
Practice Address - Phone:419-464-8915
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty