Healthcare Provider Details

I. General information

NPI: 1740216654
Provider Name (Legal Business Name): JANELL D'ANNE REID AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 07/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12791 NEWPORT AVE SUITE 101
TUSTIN CA
92780-2751
US

IV. Provider business mailing address

12791 NEWPORT AVE SUITE 101
TUSTIN CA
92780-2751
US

V. Phone/Fax

Practice location:
  • Phone: 714-731-6549
  • Fax: 714-730-5372
Mailing address:
  • Phone: 714-731-6549
  • Fax: 714-730-5372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberAU566
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: