Healthcare Provider Details

I. General information

NPI: 1457950669
Provider Name (Legal Business Name): EAST ORLANDO AUDIOLOGY HEARING & WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2020
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11602 LAKE UNDERHILL RD STE 130
ORLANDO FL
32825-4460
US

IV. Provider business mailing address

11602 LAKE UNDERHILL RD STE 130
ORLANDO FL
32825-4460
US

V. Phone/Fax

Practice location:
  • Phone: 407-635-8497
  • Fax: 407-627-1680
Mailing address:
  • Phone: 407-635-8497
  • Fax: 407-627-1680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State

VIII. Authorized Official

Name: DR. GREGORY KYLE CLIFTON
Title or Position: OWNER
Credential: AU.D.
Phone: 407-635-8497