Healthcare Provider Details

I. General information

NPI: 1083665798
Provider Name (Legal Business Name): KEVIN KRISTALOVICH AUD, CCC-A
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 11/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 N 140TH AVE STE 107
GOODYEAR AZ
85395
US

IV. Provider business mailing address

PO BOX 12550
BELFAST ME
04915-4016
US

V. Phone/Fax

Practice location:
  • Phone: 623-535-8770
  • Fax: 623-535-8771
Mailing address:
  • Phone: 623-535-8770
  • Fax: 623-535-8771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberDA2024
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: