1710427158 NPI number — ROSEVILLE DIAGNOSTIC HEARING CENTER, LLC

Table of content: (NPI 1710427158)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710427158 NPI number — ROSEVILLE DIAGNOSTIC HEARING CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROSEVILLE DIAGNOSTIC HEARING CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710427158
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1411 SECRET RAVINE PKWY
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95661-6041
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1411 SECRET RAVINE PKWY
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95661-6041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-203-8145
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/05/2017

Additional Information

Authorized Official

Authorized Official Last Name:
YOUNG
Authorized Official First Name:
ROSELYNN
Authorized Official Middle Name:
GAMBOA
Authorized Official Title or Position:
AUDIOLOGIST/MANAGER
Authorized Official Telephone Number:
916-203-8145

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  AU2197 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com