=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710427158
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROSEVILLE DIAGNOSTIC HEARING CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2017
-----------------------------------------------------
Last Update Date | 03/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1411 SECRET RAVINE PKWY SUITE 120
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95661-6041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-203-8145
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1411 SECRET RAVINE PKWY SUITE 120
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95661-6041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUDIOLOGIST/MANAGER
-----------------------------------------------------
Name | ROSELYNN GAMBOA YOUNG
-----------------------------------------------------
Credential | AU.D
-----------------------------------------------------
Telephone | 916-203-8145
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | AU2197
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------