Provider Demographics
NPI:1942501325
Name:PHC OF BUFFALO GROVE AUDIOLOGY
Entity Type:Organization
Organization Name:PHC OF BUFFALO GROVE AUDIOLOGY
Other - Org Name:PORTRAIT HEALTH CENTERS OF BUFFALO GROVE AUDIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:MELISSA
Authorized Official - Last Name:MATTINGLY
Authorized Official - Suffix:
Authorized Official - Credentials:AUD, CCC-A
Authorized Official - Phone:847-868-3435
Mailing Address - Street 1:150 W HALF DAY RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-6591
Mailing Address - Country:US
Mailing Address - Phone:847-868-3435
Mailing Address - Fax:847-859-5885
Practice Address - Street 1:150 W HALF DAY RD
Practice Address - Street 2:SUITE 105
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-6591
Practice Address - Country:US
Practice Address - Phone:847-868-3435
Practice Address - Fax:847-859-5885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-16
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147-000978237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Single Specialty