Healthcare Provider Details

I. General information

NPI: 1245625516
Provider Name (Legal Business Name): DAVID ROSS ARCHIE HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 04/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 W OLIVE AVE STE 100
MERCED CA
95348
US

IV. Provider business mailing address

6700 WASHINGTON AVE S
EDEN PRAIRIE MN
55344-3405
US

V. Phone/Fax

Practice location:
  • Phone: 209-722-3325
  • Fax: 209-383-0802
Mailing address:
  • Phone: 612-351-1529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: