1801053046 NPI number — TRI STATE AUDIOLOGY & VESTIBULAR CENTER

Table of content: PENNY MCCLURE NCC, MS MHC (NPI 1396066445)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801053046 NPI number — TRI STATE AUDIOLOGY & VESTIBULAR CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI STATE AUDIOLOGY & VESTIBULAR CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801053046
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1370 RAMAR RD
Provider Second Line Business Mailing Address:
SUIE D
Provider Business Mailing Address City Name:
BULLHEAD CITY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86442-7117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-758-3337
Provider Business Mailing Address Fax Number:
928-758-4404

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1677 QUARTZ CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BULLHEAD CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86442-6016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-758-9130
Provider Business Practice Location Address Fax Number:
928-758-4404
Provider Enumeration Date:
05/16/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WATERS
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
DALE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
928-758-3337

Provider Taxonomy Codes

  • Taxonomy code: 332S00000X , with the licence number:  DA4586 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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