Healthcare Provider Details

I. General information

NPI: 1093719874
Provider Name (Legal Business Name): OMALLAH BUSH AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 01/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 W STATE ST
ALLIANCE OH
44601-3613
US

IV. Provider business mailing address

8800 SE SUNNYSIDE RD STE 300N
CLACKAMAS OR
97015-5703
US

V. Phone/Fax

Practice location:
  • Phone: 330-821-2012
  • Fax: 330-823-4799
Mailing address:
  • Phone: 281-286-2999
  • Fax: 512-607-4893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberA-01176
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: