Basic Information
| Provider Information | |||||||||
| NPI: | 1114010717 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AUDIOLOGY ASSOCIATES OF SALT LAKE CITY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 508 E SOUTH TEMPLE | ||||||||
| Address2: | STE 203 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841021013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013648692 | ||||||||
| FaxNumber: | 8013640807 | ||||||||
| Practice Location | |||||||||
| Address1: | 508 E SOUTH TEMPLE | ||||||||
| Address2: | STE 203 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841021013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013648692 | ||||||||
| FaxNumber: | 8013640807 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 09/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | SCOTT | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | REX | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8013648692 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MS,CCC-A | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 1000464101 | UT | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 528504184 | 01 | UT | PEHP | OTHER | 528504184003 | 05 | UT | MEDICAID | 528504184 | 01 | UT | ALTIUS | OTHER | 528504184 | 01 | TX | UNITED MED CHOICE | OTHER | 52850418400001 | 01 | UT | BCBS OF UTAH | OTHER | 4500045 | 01 | TX | UNITED HEALTH CARE FLEX | OTHER | 528504184 | 01 | UT | EDUCATOR MUTUAL | OTHER | 528504184 | 05 | UT | MEDICAID | 190171900 | 01 | KY | US DEPT OF LABOR | OTHER | TPRA06318 | 05 | UT | MEDICAID | 100505792 | 05 | NV | MEDICAID | 528504184 | 01 | CA | UNITED MINE WORKERS | OTHER | 154998 | 01 | UT | DMBA | OTHER | 528504184 | 01 | KY | MAILHANDLERS | OTHER |