Provider Demographics
NPI:1104260983
Name:AUDIOLOGY DISTRIBUTION
Entity type:Organization
Organization Name:AUDIOLOGY DISTRIBUTION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTRACTING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LILLIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-478-8770
Mailing Address - Street 1:10455 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-4237
Mailing Address - Country:US
Mailing Address - Phone:561-478-8770
Mailing Address - Fax:561-598-7230
Practice Address - Street 1:4024 PARKMEAD
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-3901
Practice Address - Country:US
Practice Address - Phone:614-801-9164
Practice Address - Fax:614-875-8529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-23
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03102231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0079935Medicaid