Basic Information
| Provider Information | |||||||||
| NPI: | 1669645776 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALVIRA | ||||||||
| FirstName: | PROVIDENCE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | AU.D CCC-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12927 SLEEPY WIND ST | ||||||||
| Address2: | |||||||||
| City: | MOORPARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930212935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109893092 | ||||||||
| FaxNumber: | 8055303989 | ||||||||
| Practice Location | |||||||||
| Address1: | 6367 ALVARADO CT | ||||||||
| Address2: | STE 101 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921204904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195837002 | ||||||||
| FaxNumber: | 6195839404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2008 | ||||||||
| LastUpdateDate: | 06/30/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | 1745 | CA | Y | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | 1669645776 | 05 | CA | MEDICAID |