Provider Demographics
NPI:1881868784
Name:PORTAGE VALLEY HEARING, LLC
Entity type:Organization
Organization Name:PORTAGE VALLEY HEARING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/AUDIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:LEANN
Authorized Official - Last Name:KRUKEMYER
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:419-287-2201
Mailing Address - Street 1:133 E. FRONT STREET
Mailing Address - Street 2:P. O. BOX 687
Mailing Address - City:PEMBERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43450
Mailing Address - Country:US
Mailing Address - Phone:419-287-2201
Mailing Address - Fax:419-287-2202
Practice Address - Street 1:133 E FRONT ST
Practice Address - Street 2:
Practice Address - City:PEMBERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43450-7032
Practice Address - Country:US
Practice Address - Phone:419-287-2201
Practice Address - Fax:419-287-2202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
Provider Identifiers
StateIdentifier IDID TypeIssuer
4037611Medicare PIN