1962570051 NPI number — MARCIA SMITH BLANK AU.D.

Table of content: MARCIA SMITH BLANK AU.D. (NPI 1962570051)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962570051 NPI number — MARCIA SMITH BLANK AU.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLANK
Provider First Name:
MARCIA
Provider Middle Name:
SMITH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AU.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HEARING CENTER
Provider Other First Name:
GARDENA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
AU.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1962570051
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1300 W 155TH ST STE 107
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARDENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90247-4049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-327-5001
Provider Business Mailing Address Fax Number:
310-327-2349

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 W 155TH ST
Provider Second Line Business Practice Location Address:
107
Provider Business Practice Location Address City Name:
GARDENA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90247-4049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-327-5001
Provider Business Practice Location Address Fax Number:
310-327-2349
Provider Enumeration Date:
11/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 237600000X , with the licence number:  HA1505 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 237600000X , with the licence number: AU751 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: AU0007510 . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: AUD751B . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: HA0015051 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: AU0007510 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: AU0007511 . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: HA0015050 . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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