Provider Demographics
NPI:1124170303
Name:GLENDALE PROFESSIONAL HEARING CENTER,INC
Entity type:Organization
Organization Name:GLENDALE PROFESSIONAL HEARING CENTER,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUNDLES
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:818-243-0680
Mailing Address - Street 1:372 ARDEN AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-1196
Mailing Address - Country:US
Mailing Address - Phone:818-243-0680
Mailing Address - Fax:
Practice Address - Street 1:372 ARDEN AVE STE 101
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-1196
Practice Address - Country:US
Practice Address - Phone:818-243-0680
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAUD1257231H00000X
CAHA-2514332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Not Answered332S00000XSuppliersHearing Aid Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHA-2514Medicaid
CAAU0012570Medicaid