Provider Demographics
NPI:1598981524
Name:PRINCETON AUDIOLOGY CLINIC, INC.,
Entity Type:Organization
Organization Name:PRINCETON AUDIOLOGY CLINIC, INC.,
Other - Org Name:DBA BLUE RIDGE HEARING AND BALANCE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:DESMOND
Authorized Official - Suffix:
Authorized Official - Credentials:AUD, CCC-A
Authorized Official - Phone:304-487-2487
Mailing Address - Street 1:508 NEW HOPE ROAD
Mailing Address - Street 2:SUITE #19
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2272
Mailing Address - Country:US
Mailing Address - Phone:304-487-2487
Mailing Address - Fax:304-431-3367
Practice Address - Street 1:2001 STADIUM DRIVE
Practice Address - Street 2:SUITE D
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701
Practice Address - Country:US
Practice Address - Phone:304-324-2954
Practice Address - Fax:304-324-2955
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRINCETON AUDIOLOGY CLINIC, INC., DBA BLUE RIDGE HEARING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-18
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No332S00000XSuppliersHearing Aid EquipmentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CC375OtherPALMETTO GBA RR MEDICARE
WV3810002482Medicaid
PR9319052OtherMEDICARE PALMETTO GBA PTAN NUMBER
WV3810002482Medicaid