=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669081469
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK DATUIN AU.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2020
-----------------------------------------------------
Last Update Date | 07/31/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26302 LA PAZ RD STE 107
-----------------------------------------------------
City | MISSION VIEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92691-5327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-855-7898
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3734 SEPULVEDA BLVD
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90505-2513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-803-9496
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | AU3353
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------