Healthcare Provider Details

I. General information

NPI: 1457976888
Provider Name (Legal Business Name): TONI BAILEY HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TONI ST AUBIN

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 MCCULLOCH BLVD N STE 100
LAKE HAVASU CITY AZ
86403-6559
US

IV. Provider business mailing address

1760 MCCULLOCH BLVD N STE 100
LAKE HAVASU CITY AZ
86403-6559
US

V. Phone/Fax

Practice location:
  • Phone: 928-854-5368
  • Fax:
Mailing address:
  • Phone: 928-854-5368
  • Fax: 928-854-4462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHADE10111
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: