Healthcare Provider Details

I. General information

NPI: 1417971110
Provider Name (Legal Business Name): ROBERT FAILLACE AUD, CCC/A
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3590 CAMINO DEL RIO N SUITE# 201
SAN DIEGO CA
92108-1707
US

IV. Provider business mailing address

3590 CAMINO DEL RIO N SUITE# 201
SAN DIEGO CA
92108-1707
US

V. Phone/Fax

Practice location:
  • Phone: 619-810-1204
  • Fax:
Mailing address:
  • Phone: 619-810-1204
  • Fax: 619-517-3233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAU1380
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberAU1380
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: