Provider Demographics
NPI:1942282850
Name:MT. HOOD HEARING AID CENTER, INC.
Entity Type:Organization
Organization Name:MT. HOOD HEARING AID CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / HEARING AID DISPENSER
Authorized Official - Prefix:MR
Authorized Official - First Name:VLADIMIR
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:HEARING SPECIALIST
Authorized Official - Phone:503-669-8070
Mailing Address - Street 1:PO BOX 16862
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0862
Mailing Address - Country:US
Mailing Address - Phone:503-669-8070
Mailing Address - Fax:503-236-3513
Practice Address - Street 1:4105 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1646
Practice Address - Country:US
Practice Address - Phone:503-669-8070
Practice Address - Fax:503-236-3513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0310216371237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR233180Medicaid