Healthcare Provider Details

I. General information

NPI: 1700181815
Provider Name (Legal Business Name): JASON BALSOM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2011
Last Update Date: 08/05/2022
Certification Date: 08/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17972 SKY PARK CIR STE D
IRVINE CA
92614-4402
US

IV. Provider business mailing address

1106 E 17TH ST STE E
SANTA ANA CA
92701-2603
US

V. Phone/Fax

Practice location:
  • Phone: 714-547-6822
  • Fax: 714-543-8130
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHA7519
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: