Provider Demographics
NPI:1720098536
Name:JOHN W. LOOPER JR. SPEECH & HEARING CLINIC
Entity Type:Organization
Organization Name:JOHN W. LOOPER JR. SPEECH & HEARING CLINIC
Other - Org Name:LOOPER SPEECH & HEARING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHIE
Authorized Official - Middle Name:LANE
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:706-226-4623
Mailing Address - Street 1:1011 PROFESSIONAL BLVD
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2506
Mailing Address - Country:US
Mailing Address - Phone:706-226-4623
Mailing Address - Fax:706-278-0580
Practice Address - Street 1:1011 PROFESSIONAL BLVD
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2506
Practice Address - Country:US
Practice Address - Phone:706-226-4623
Practice Address - Fax:706-278-0580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAJ213493231H00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000196314AMedicaid
GAGRP7924Medicare PIN