Provider Demographics
NPI:1841530912
Name:LAKE PROFESSIONAL HEARING AID CENTER
Entity type:Organization
Organization Name:LAKE PROFESSIONAL HEARING AID CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:A
Authorized Official - Last Name:FRASIER
Authorized Official - Suffix:
Authorized Official - Credentials:BC-HIS
Authorized Official - Phone:573-346-4500
Mailing Address - Street 1:648 N BUSINESS ROUTE 5
Mailing Address - Street 2:
Mailing Address - City:CAMDENTON
Mailing Address - State:MO
Mailing Address - Zip Code:65020-2642
Mailing Address - Country:US
Mailing Address - Phone:573-346-4500
Mailing Address - Fax:573-346-0480
Practice Address - Street 1:648 N BUSINESS ROUTE 5
Practice Address - Street 2:
Practice Address - City:CAMDENTON
Practice Address - State:MO
Practice Address - Zip Code:65020-2642
Practice Address - Country:US
Practice Address - Phone:573-346-4500
Practice Address - Fax:573-346-0480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-26
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332S00000XSuppliersHearing Aid EquipmentGroup - Single Specialty