Provider Demographics
NPI:1700331303
Name:PROFESSIONAL AUDIOLOGY & HEARING CENTER INC
Entity Type:Organization
Organization Name:PROFESSIONAL AUDIOLOGY & HEARING CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:MCGARGILL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:402-558-0440
Mailing Address - Street 1:4509 LEAVENWORTH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68106-1418
Mailing Address - Country:US
Mailing Address - Phone:402-558-0440
Mailing Address - Fax:402-558-7794
Practice Address - Street 1:4509 LEAVENWORTH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68106-1418
Practice Address - Country:US
Practice Address - Phone:402-558-0440
Practice Address - Fax:402-558-7794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========00Medicaid