Healthcare Provider Details

I. General information

NPI: 1861484057
Provider Name (Legal Business Name): PHILIP BRUCE MELTMAR AUD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 10/12/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 CENTRAL AVE BLDG 1750
JBPHH HI
96860-4908
US

IV. Provider business mailing address

315 CANYONSIDE WAY
OCEANSIDE CA
92054-7148
US

V. Phone/Fax

Practice location:
  • Phone: 808-474-0625
  • Fax:
Mailing address:
  • Phone: 760-725-1637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number147-000600
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: