Basic Information
| Provider Information | |||||||||
| NPI: | 1730414343 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLBERT | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | MR. | ||||||||
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| OtherLastName: | COLBERT | ||||||||
| OtherFirstName: | MIKE | ||||||||
| OtherMiddleName: | SCOTT | ||||||||
| OtherNamePrefix: | MR. | ||||||||
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| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 215 SHUMAN BLVD STE 401 | ||||||||
| Address2: | |||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605638123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303035380 | ||||||||
| FaxNumber: | 6303035385 | ||||||||
| Practice Location | |||||||||
| Address1: | 1551 W GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | GROVER BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934332226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054748154 | ||||||||
| FaxNumber: | 8054748156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2009 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 237700000X | 5026 | CA | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.