Healthcare Provider Details

I. General information

NPI: 1598204745
Provider Name (Legal Business Name): INNOVATIVE HEARING CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2017
Last Update Date: 08/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3975 JACKSON ST STE 204
RIVERSIDE CA
92503
US

IV. Provider business mailing address

3975 JACKSON ST STE 204
RIVERSIDE CA
92503-3948
US

V. Phone/Fax

Practice location:
  • Phone: 951-977-9121
  • Fax: 951-977-9317
Mailing address:
  • Phone: 951-977-9121
  • Fax: 951-977-9317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberAU1083
License Number StateCA

VIII. Authorized Official

Name: MIRIAM E TEELE
Title or Position: OWNER/MANAGER
Credential: AUD
Phone: 951-352-7920