Provider Demographics
NPI:1316163918
Name:GREGORY BROTHERTON
Entity type:Organization
Organization Name:GREGORY BROTHERTON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HEARING AID DISPENSER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROTHERTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-223-2436
Mailing Address - Street 1:819 S STATE HIGHWAY 49
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642-2622
Mailing Address - Country:US
Mailing Address - Phone:209-223-2436
Mailing Address - Fax:209-257-0729
Practice Address - Street 1:819 S STATE HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-2622
Practice Address - Country:US
Practice Address - Phone:209-223-2436
Practice Address - Fax:209-257-0729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA2805237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty