Provider Demographics
NPI:1841408416
Name:PROFESSIONAL HEARING GROUP
Entity Type:Organization
Organization Name:PROFESSIONAL HEARING GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CASSIDY
Authorized Official - Middle Name:K
Authorized Official - Last Name:ARCHIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-322-3332
Mailing Address - Street 1:968 GILCHRIST ST
Mailing Address - Street 2:
Mailing Address - City:WHEATLAND
Mailing Address - State:WY
Mailing Address - Zip Code:82201-2932
Mailing Address - Country:US
Mailing Address - Phone:307-682-3399
Mailing Address - Fax:307-682-3436
Practice Address - Street 1:407 S MEDICAL ARTS CT
Practice Address - Street 2:SUITE F
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3372
Practice Address - Country:US
Practice Address - Phone:307-682-3399
Practice Address - Fax:307-682-3436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYA931231H00000X
WYA960231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYPENDINGMedicare ID - Type Unspecified