Healthcare Provider Details

I. General information

NPI: 1164831426
Provider Name (Legal Business Name): EXCEPTIONAL HEARING SERVICES OF NORTHERN CALIFORNIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2014
Last Update Date: 09/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4340 REDWOOD HWY # A12
SAN RAFAEL CA
94903-2121
US

IV. Provider business mailing address

4340 REDWOOD HWY # A12
SAN RAFAEL CA
94903-2121
US

V. Phone/Fax

Practice location:
  • Phone: 415-499-7766
  • Fax: 415-491-1336
Mailing address:
  • Phone: 415-499-7766
  • Fax: 415-491-1336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberAU 2679
License Number StateCA

VIII. Authorized Official

Name: DR. KELLY GIBSON
Title or Position: DR. OF AUDIOLOGY/OWNER
Credential: AU.D.
Phone: 415-499-7766