Provider Demographics
NPI:1972716066
Name:THE AUDIOLOGY OFFICES LLC
Entity type:Organization
Organization Name:THE AUDIOLOGY OFFICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, AUDIOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:DEPAOLO
Authorized Official - Last Name:WIETSMA
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:804-435-0758
Mailing Address - Street 1:PO BOX 1911
Mailing Address - Street 2:45 N MAIN ST
Mailing Address - City:KILMARNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22482-1911
Mailing Address - Country:US
Mailing Address - Phone:804-435-0758
Mailing Address - Fax:804-435-7226
Practice Address - Street 1:45 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KILMARNOCK
Practice Address - State:VA
Practice Address - Zip Code:22482-1911
Practice Address - Country:US
Practice Address - Phone:804-435-0758
Practice Address - Fax:804-435-7226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2101 001400231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACO7052Medicare PIN