Basic Information
Provider Information | |||||||||
NPI: | 1831465301 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TREASURE VALLEY HEARING AND BALANCE CLINIC, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TREASURE VALLEY HEARING | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1084 N COLE RD | ||||||||
Address2: |   | ||||||||
City: | BOISE | ||||||||
State: | ID | ||||||||
PostalCode: | 837048642 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2083770019 | ||||||||
FaxNumber: | 2083770313 | ||||||||
Practice Location | |||||||||
Address1: | 745 S PROGRESS AVE | ||||||||
Address2: |   | ||||||||
City: | MERIDIAN | ||||||||
State: | ID | ||||||||
PostalCode: | 836425619 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2083770019 | ||||||||
FaxNumber: | 2083770313 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/28/2012 | ||||||||
LastUpdateDate: | 03/28/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ELCOX | ||||||||
AuthorizedOfficialFirstName: | JACQUIE | ||||||||
AuthorizedOfficialMiddleName: | ANNE | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/ PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2083770019 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | BC-HIS | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |   | 231H00000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist |   |
No ID Information.