Provider Demographics
NPI:1720687890
Name:PRAIRIE SEA HEARING CENTER LLC
Entity Type:Organization
Organization Name:PRAIRIE SEA HEARING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:RAISEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-805-8057
Mailing Address - Street 1:3000 N 14TH ST STE 3C
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0697
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3000 N 14TH ST STE 3C
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0697
Practice Address - Country:US
Practice Address - Phone:701-805-8057
Practice Address - Fax:701-751-3168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-20
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1477988459Medicaid
ND1790216844Medicaid