Provider Demographics
NPI:1376827303
Name:WATERFORD HEARING CENTER
Entity type:Organization
Organization Name:WATERFORD HEARING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:GRSKOVIC
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:219-961-5077
Mailing Address - Street 1:3777 N WOZNIAK RD
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-9284
Mailing Address - Country:US
Mailing Address - Phone:219-961-5077
Mailing Address - Fax:
Practice Address - Street 1:3777 N WOZNIAK RD
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-9284
Practice Address - Country:US
Practice Address - Phone:219-961-5077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23002485A237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Single Specialty