Provider Demographics
NPI:1598899478
Name:CUSTOM HEARING CARE INC
Entity Type:Organization
Organization Name:CUSTOM HEARING CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUDIOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:GOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MACCCA
Authorized Official - Phone:248-474-8161
Mailing Address - Street 1:25882 ORCHARD LAKE RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-1292
Mailing Address - Country:US
Mailing Address - Phone:248-474-8161
Mailing Address - Fax:248-474-2966
Practice Address - Street 1:25882 ORCHARD LAKE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-1292
Practice Address - Country:US
Practice Address - Phone:248-474-8161
Practice Address - Fax:248-474-2966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000305231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2609400Medicaid