Basic Information
| Provider Information | |||||||||
| NPI: | 1538107289 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST COAST HEARING & BALANCE CENTER | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 301 S MOORPARK RD | ||||||||
| Address2: | |||||||||
| City: | THOUSAND OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913611008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104775558 | ||||||||
| FaxNumber: | 3104777281 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 S MOORPARK RD | ||||||||
| Address2: | |||||||||
| City: | THOUSAND OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913611008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104775558 | ||||||||
| FaxNumber: | 3104777281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FRAZER | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3104775558 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | AU.D., PHD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | GAU000993 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | GAU000993 | 05 | CA | MEDICAID |