Healthcare Provider Details

I. General information

NPI: 1801409032
Provider Name (Legal Business Name): CLEMENTE MORALES AUD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2020
Last Update Date: 08/27/2020
Certification Date: 08/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5757 W THUNDERBIRD RD STE E156
GLENDALE AZ
85306-5602
US

IV. Provider business mailing address

2501 COTTONTAIL LN
SOMERSET NJ
08873-5125
US

V. Phone/Fax

Practice location:
  • Phone: 602-978-5187
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberDA12580
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: