Healthcare Provider Details

I. General information

NPI: 1790231066
Provider Name (Legal Business Name): SRIVATHSAN NALLUR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HEARUSA, 16940 SLOVER AVE SUITE A
FONTANA CA
92337-7566
US

IV. Provider business mailing address

9346 MEADOW ST
RANCHO CUCAMONGA CA
91730-5652
US

V. Phone/Fax

Practice location:
  • Phone: 909-854-8569
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number10463
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberHT 9508
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: