Provider Demographics
NPI:1285740886
Name:PROGRESSIVE AUDIOLOGY CENTER, INC.
Entity type:Organization
Organization Name:PROGRESSIVE AUDIOLOGY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRIQUES
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:770-592-4744
Mailing Address - Street 1:2230 TOWNE LAKE PARKWAY
Mailing Address - Street 2:BLDG 800, SUITE 100
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189
Mailing Address - Country:US
Mailing Address - Phone:770-592-4744
Mailing Address - Fax:
Practice Address - Street 1:2230 TOWNE LAKE PKWY
Practice Address - Street 2:BUILDING 800 SUITE 120
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-5540
Practice Address - Country:US
Practice Address - Phone:770-592-4744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
237600000X
GAAUD001690237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4289Medicare ID - Type Unspecified