Provider Demographics
NPI:1720280894
Name:KENOSHA HEARING AID CENTERS
Entity type:Organization
Organization Name:KENOSHA HEARING AID CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:B
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:HIS
Authorized Official - Phone:262-654-4703
Mailing Address - Street 1:2527 75TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-1407
Mailing Address - Country:US
Mailing Address - Phone:262-654-4703
Mailing Address - Fax:262-654-4703
Practice Address - Street 1:2527 75TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-1407
Practice Address - Country:US
Practice Address - Phone:262-654-4703
Practice Address - Fax:262-654-4703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42857000Medicaid