Provider Demographics
NPI:1659702157
Name:OMAK AUDIOLOGY CENTER, LLC
Entity Type:Organization
Organization Name:OMAK AUDIOLOGY CENTER, LLC
Other - Org Name:OMAK AUDIOLOGY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/AUDIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MOLLERUP
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:509-322-5995
Mailing Address - Street 1:208 S MAIN ST # 29
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841-9755
Mailing Address - Country:US
Mailing Address - Phone:509-322-5995
Mailing Address - Fax:
Practice Address - Street 1:506 RIVERSIDE DRIVE, # B
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841
Practice Address - Country:US
Practice Address - Phone:509-322-5995
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALD60323941237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Single Specialty