Basic Information
| Provider Information | |||||||||
| NPI: | 1215993704 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE SPEECH & HEARING CENTER | ||||||||
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| OtherOrganizationName: | PROVIDENCE SPEECH AND HEARING CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 W LA VETA AVE | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928684203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145093000 | ||||||||
| FaxNumber: | 7147443841 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 W PROVIDENCE AVE | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928683808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146394990 | ||||||||
| FaxNumber: | 7147443841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2006 | ||||||||
| LastUpdateDate: | 10/14/2022 | ||||||||
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| AuthorizedOfficialLastName: | ELQURA | ||||||||
| AuthorizedOfficialFirstName: | MARIAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTRACT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7145093000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 231H00000X | CA | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 237700000X | CA | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 252Y00000X | N | Agencies | Early Intervention Provider Agency | 235Z00000X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | ZZZ01182Z | 01 | CA | BLUE SHIELD SPEECH | OTHER | GAU000910 | 05 | CA | MEDICAID | ZZZ05424Z | 01 | CA | BLUE SHIELD OT | OTHER | GSP000640 | 05 | CA | MEDICAID | ZZZ02320Z | 01 | CA | BLUE SHIELD AUDIO | OTHER | ZZZ43525Z | 01 | CA | BLUE SHIELD HEARING AID | OTHER |