Basic Information
| Provider Information | |||||||||
| NPI: | 1366894354 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAN DIEGO HEARING AIDS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | NUEAR HEARING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4504 CLAIREMONT MESA BLVD | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921172065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192750011 | ||||||||
| FaxNumber: | 6192750013 | ||||||||
| Practice Location | |||||||||
| Address1: | 4504 CLAIREMONT MESA BLVD | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921172065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192750011 | ||||||||
| FaxNumber: | 6192750013 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2016 | ||||||||
| LastUpdateDate: | 07/01/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KELLY | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6192750011 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332S00000X | Y | Suppliers | Hearing Aid Equipment |
No ID Information.