Provider Demographics
NPI:1821215955
Name:PACIFIC NORTHWEST HEARING AID SERVICE LLC
Entity Type:Organization
Organization Name:PACIFIC NORTHWEST HEARING AID SERVICE LLC
Other - Org Name:LEE R. CHAMP
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER HEARING AID DEALER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:CHAMP
Authorized Official - Suffix:
Authorized Official - Credentials:NBCHIS
Authorized Official - Phone:509-527-3521
Mailing Address - Street 1:704 W POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2749
Mailing Address - Country:US
Mailing Address - Phone:509-527-3521
Mailing Address - Fax:
Practice Address - Street 1:704 W POPLAR ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2749
Practice Address - Country:US
Practice Address - Phone:509-527-3521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHA715332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA=========Medicare UPIN