Healthcare Provider Details

I. General information

NPI: 1487042875
Provider Name (Legal Business Name): KELLY MICHELLE SCOGGINS HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2015
Last Update Date: 01/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2934 LINCOLN AVE
SAN DIEGO CA
92104-2909
US

IV. Provider business mailing address

2934 LINCOLN AVE
SAN DIEGO CA
92104-2909
US

V. Phone/Fax

Practice location:
  • Phone: 619-283-8400
  • Fax: 619-283-8086
Mailing address:
  • Phone: 619-283-8400
  • Fax: 619-283-8086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235500000X
TaxonomySpeech/Language/Hearing Specialist/Technologist
License NumberHAD7317
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHAD7317
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: