Basic Information
| Provider Information | |||||||||
| NPI: | 1639304173 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAIRFIELD | ||||||||
| FirstName: | GLEN | ||||||||
| MiddleName: | ERIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE #55745 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900745745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614788770 | ||||||||
| FaxNumber: | 5616888877 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 N 9TH ST | ||||||||
| Address2: | |||||||||
| City: | GROVER BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934332122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054811523 | ||||||||
| FaxNumber: | 8054811269 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2009 | ||||||||
| LastUpdateDate: | 08/06/2009 | ||||||||
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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 | 237700000X | 2915 | CA | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.