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General NPI Number Information
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NPI Number | 1407212525
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Entity Type | Organization
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Legal Business Name | FOREST LAKE AUDIOLOGY LLC
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Dates
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Enumeration Date | 01/05/2016
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Last Update Date | 03/16/2016
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Provider Practice Location Address
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Address Line | 5301 N TRENHOLM RD SUITE A
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City | COLUMBIA
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State | SC
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Zip | 29206-3226
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Country | US
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Telephone | 803-888-7330
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Fax |
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Provider Business Mailing Address
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Address Line | 5301 N TRENHOLM RD SUITE A
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City | COLUMBIA
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State | SC
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Zip | 29206-3226
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Country | US
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Telephone | 803-888-7330
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. TODD GIBSON
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Credential | AUDIOLOGIST
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Telephone | 803-888-7330
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 231H00000X
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Taxonomy Name | Audiologist
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License Number | SC3435
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License Number State | SC
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