Healthcare Provider Details

I. General information

NPI: 1295123669
Provider Name (Legal Business Name): EAST VALLEY AUDIOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2015
Last Update Date: 01/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 SO. BUENA VISTA SUITE 320-A
BURBANK CA
91505
US

IV. Provider business mailing address

191 SO. BUENA VISTA SUITE 320-A
BURBANK CA
91505
US

V. Phone/Fax

Practice location:
  • Phone: 818-559-9580
  • Fax:
Mailing address:
  • Phone: 818-559-9580
  • Fax: 818-559-1341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number StateCA

VIII. Authorized Official

Name: WARREN S. LINE JR.
Title or Position: PRESIDENT
Credential:
Phone: 818-559-9727