Basic Information
| Provider Information | |||||||||
| NPI: | 1457950669 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST ORLANDO AUDIOLOGY HEARING & WELLNESS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11602 LAKE UNDERHILL RD STE 130 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328254460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076358497 | ||||||||
| FaxNumber: | 4076271680 | ||||||||
| Practice Location | |||||||||
| Address1: | 11602 LAKE UNDERHILL RD STE 130 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328254460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076358497 | ||||||||
| FaxNumber: | 4076271680 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2020 | ||||||||
| LastUpdateDate: | 10/19/2020 | ||||||||
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| AuthorizedOfficialLastName: | CLIFTON | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | KYLE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4076358497 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | AU.D. | ||||||||
| NPICertificationDate: | 10/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0700X | N | Ambulatory Health Care Facilities | Clinic/Center | Hearing and Speech | 332S00000X | N | Suppliers | Hearing Aid Equipment | 231H00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.