Basic Information
| Provider Information | |||||||||
| NPI: | 1417056201 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THEOBALD | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | AU.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1084 N COLE RD | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837048642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083770019 | ||||||||
| FaxNumber: | 2083770313 | ||||||||
| Practice Location | |||||||||
| Address1: | 1084 N COLE RD | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837048642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083770019 | ||||||||
| FaxNumber: | 2083770313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 10/31/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 237700000X | N | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 231H00000X | Y | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.