Provider Demographics
NPI:1710239967
Name:PROFESSIONAL AUDIOLOGICAL SERVICES, INC.
Entity Type:Organization
Organization Name:PROFESSIONAL AUDIOLOGICAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLTHARP MORTON
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:901-372-0040
Mailing Address - Street 1:5108 STAGE RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38134-3164
Mailing Address - Country:US
Mailing Address - Phone:901-372-0040
Mailing Address - Fax:901-372-8685
Practice Address - Street 1:5118 STAGE RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38134-3166
Practice Address - Country:US
Practice Address - Phone:901-372-0040
Practice Address - Fax:901-372-8685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-12
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNA103231HA2500X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231HA2500XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology SupplierGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1529238Medicaid