Provider Demographics
NPI:1962570051
Name:BLANK, MARCIA SMITH (AUD)
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:SMITH
Last Name:BLANK
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:GARDENA
Other - Middle Name:
Other - Last Name:HEARING CENTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:AUD
Mailing Address - Street 1:1300 W 155TH ST STE 107
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4049
Mailing Address - Country:US
Mailing Address - Phone:310-327-5001
Mailing Address - Fax:310-327-2349
Practice Address - Street 1:1300 W 155TH ST
Practice Address - Street 2:107
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-4049
Practice Address - Country:US
Practice Address - Phone:310-327-5001
Practice Address - Fax:310-327-2349
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA1505237600000X
CAAU751237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
AU0007510OtherBLUE SHIELD
AUD751BOtherMEDICARE
CAHA0015051Medicaid
CAAU0007510Medicaid
AU0007511OtherBLUE SHIELD
HA0015050OtherBLUE SHIELD
AUD751BMedicare UPIN
AUD751BOtherMEDICARE
CAHA0015051Medicaid