Basic Information
| Provider Information | |||||||||
| NPI: | 1972833481 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTERN IDAHO AUDIOLOGY, LLC | ||||||||
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| OtherOrganizationName: | POCATELLO HEARING ZONE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7808 W POCATELLO CREEK RD | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832019058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082351544 | ||||||||
| FaxNumber: | 2082380021 | ||||||||
| Practice Location | |||||||||
| Address1: | 4155 YELLOWSTONE AVE | ||||||||
| Address2: | PINE RIDGE MALL | ||||||||
| City: | CHUBBUCK | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832022345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082380020 | ||||||||
| FaxNumber: | 2082380021 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2010 | ||||||||
| LastUpdateDate: | 01/05/2010 | ||||||||
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| AuthorizedOfficialLastName: | OLENICK | ||||||||
| AuthorizedOfficialFirstName: | KELLEY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/AUDIOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 2082380020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EASTERN IDAHO AUDIOLOGY | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | AU.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | AUD1214 | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
No ID Information.