Healthcare Provider Details

I. General information

NPI: 1689003683
Provider Name (Legal Business Name): CLAYTON PARK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2013
Last Update Date: 11/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 SEAWIND
IRVINE CA
92614-7066
US

IV. Provider business mailing address

5 SEAWIND
IRVINE CA
92614-7066
US

V. Phone/Fax

Practice location:
  • Phone: 949-285-4371
  • Fax:
Mailing address:
  • Phone: 949-285-4371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHA 7850
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: