Healthcare Provider Details

I. General information

NPI: 1831588052
Provider Name (Legal Business Name): LAND OF ENCHANTMENT AUDIOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2015
Last Update Date: 01/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

264 S CAMINO DEL PUEBLO BUILDING B
BERNALILLO NM
87004-6070
US

IV. Provider business mailing address

5901 WYOMING BLVD NE STE J-124
ALBUQUERQUE NM
87109-3838
US

V. Phone/Fax

Practice location:
  • Phone: 505-807-9805
  • Fax:
Mailing address:
  • Phone: 505-807-9805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number4526
License Number StateNM

VIII. Authorized Official

Name: DR. TOBY ELIZABETH WILSON
Title or Position: AUDIOLOGIST
Credential: AU.D.
Phone: 505-807-9805