Healthcare Provider Details

I. General information

NPI: 1417056201
Provider Name (Legal Business Name): ROGER THEOBALD AU.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 10/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1084 N COLE RD
BOISE ID
83704-8642
US

IV. Provider business mailing address

1084 N COLE RD
BOISE ID
83704-8642
US

V. Phone/Fax

Practice location:
  • Phone: 208-377-0019
  • Fax: 208-377-0313
Mailing address:
  • Phone: 208-377-0019
  • Fax: 208-377-0313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: