Healthcare Provider Details

I. General information

NPI: 1972833481
Provider Name (Legal Business Name): EASTERN IDAHO AUDIOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2010
Last Update Date: 01/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4155 YELLOWSTONE AVE PINE RIDGE MALL
CHUBBUCK ID
83202-2345
US

IV. Provider business mailing address

7808 W POCATELLO CREEK RD
POCATELLO ID
83201-9058
US

V. Phone/Fax

Practice location:
  • Phone: 208-238-0020
  • Fax: 208-238-0021
Mailing address:
  • Phone: 208-235-1544
  • Fax: 208-238-0021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberAUD1214
License Number StateID

VIII. Authorized Official

Name: DR. KELLEY J OLENICK
Title or Position: OWNER/AUDIOLOGIST
Credential: AU.D.
Phone: 208-238-0020