Provider Demographics
NPI:1932305281
Name:NORTHFORK SPEECH AND HEARING PC
Entity Type:Organization
Organization Name:NORTHFORK SPEECH AND HEARING PC
Other - Org Name:FRONTIER AUDIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LORI
Authorized Official - Middle Name:L
Authorized Official - Last Name:ARCHIE
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
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:307-322-3332
Mailing Address - Fax:307-322-3623
Practice Address - Street 1:968 GILCHRIST ST
Practice Address - Street 2:
Practice Address - City:WHEATLAND
Practice Address - State:WY
Practice Address - Zip Code:82201-2932
Practice Address - Country:US
Practice Address - Phone:307-322-3332
Practice Address - Fax:307-322-3623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE168231H00000X
WY231H00000X, 332S00000X
NE627237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No332S00000XSuppliersHearing Aid EquipmentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY104704301Medicaid
WY104704300Medicaid
WY104704300Medicaid
NE=========60Medicaid
NE=========60Medicaid