Provider Demographics
NPI:1912379173
Name:HEARING CENTER OF MOULTRIE LLC
Entity Type:Organization
Organization Name:HEARING CENTER OF MOULTRIE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRITTANY
Authorized Official - Middle Name:
Authorized Official - Last Name:REDFEARN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-985-3277
Mailing Address - Street 1:27 8TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-5500
Mailing Address - Country:US
Mailing Address - Phone:229-985-3277
Mailing Address - Fax:229-985-3280
Practice Address - Street 1:27 8TH AVE SE
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-5500
Practice Address - Country:US
Practice Address - Phone:229-985-3277
Practice Address - Fax:229-985-3280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAUD003826231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003165812AMedicaid