=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376305086
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WALNUT CREEK AUDIOLOGY CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2024
-----------------------------------------------------
Last Update Date | 01/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 OLYMPIC BLVD STE 202
-----------------------------------------------------
City | WALNUT CREEK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94596-5094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-937-4455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1900 OLYMPIC BLVD STE 202
-----------------------------------------------------
City | WALNUT CREEK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94596-5094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-937-4455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUDIOLOGIST/ OWNER/ PRESIDENT
-----------------------------------------------------
Name | DR. SAMUEL TIMOTHY JOHNSON
-----------------------------------------------------
Credential | AU.D
-----------------------------------------------------
Telephone | 707-494-4328
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 237600000X
-----------------------------------------------------
Taxonomy Name | Audiologist-Hearing Aid Fitter
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------