Provider Demographics
NPI:1578930756
Name:SUGARLOAF HEARING AID FACTORY OUTLET
Entity Type:Organization
Organization Name:SUGARLOAF HEARING AID FACTORY OUTLET
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEARING INSTRUMENT SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:GWEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:HIS
Authorized Official - Phone:404-786-6416
Mailing Address - Street 1:5900 SUGARLOAF PKWY STE 423
Mailing Address - Street 2:(SUGARLOAF MILLS OUTLET MALL)
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-7848
Mailing Address - Country:US
Mailing Address - Phone:404-786-6416
Mailing Address - Fax:
Practice Address - Street 1:5900 SUGARLOAF PKWY STE 423
Practice Address - Street 2:(SUGARLOAF MILLS OUTLET MALL)
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-7848
Practice Address - Country:US
Practice Address - Phone:404-786-6416
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAHADS000898332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment