Provider Demographics
NPI:1780983775
Name:MEDFORD/GRANTS PASS HEARING CENTERS, LLC
Entity type:Organization
Organization Name:MEDFORD/GRANTS PASS HEARING CENTERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:W
Authorized Official - Last Name:NOON
Authorized Official - Suffix:
Authorized Official - Credentials:HIS
Authorized Official - Phone:541-773-7409
Mailing Address - Street 1:712 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6712
Mailing Address - Country:US
Mailing Address - Phone:541-773-7409
Mailing Address - Fax:541-779-0612
Practice Address - Street 1:712 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6712
Practice Address - Country:US
Practice Address - Phone:541-773-7409
Practice Address - Fax:541-779-0612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORHAP-P-10124822237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500626860Medicaid