Provider Demographics
NPI:1487896114
Name:PARK PLACE DECLARANT
Entity type:Organization
Organization Name:PARK PLACE DECLARANT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MEMBER
Authorized Official - Phone:702-807-7931
Mailing Address - Street 1:PO BOX 224
Mailing Address - Street 2:
Mailing Address - City:LOGANDALE
Mailing Address - State:NV
Mailing Address - Zip Code:89021-0224
Mailing Address - Country:US
Mailing Address - Phone:702-807-7931
Mailing Address - Fax:702-398-3757
Practice Address - Street 1:2105 MCCULLOCH BLVD N
Practice Address - Street 2:#2
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6772
Practice Address - Country:US
Practice Address - Phone:702-807-7931
Practice Address - Fax:702-398-3757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-26
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZHAD5806332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment