MEDICARE: OLGA LIS AUDIOLOGY PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2355A2700X	Audiology Assistant

General Provider Information

NPI Number	:	1073003158
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLGA LIS AUDIOLOGY PC

Provider Business Mailing Address
First Line	:	209 AVENUE P STE 2A
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11204-4982
Country	:	US
Telephone Number	:	718-421-2782
Fax Number	:	718-421-2783

Provider Business Practice Location Address
First Line	:	209 AVENUE P STE 2A
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11204-4982
Country	:	US
Telephone Number	:	718-421-2782
Fax Number	:	718-421-2783

Authorized Official
Title or Position	:	OWNER
Name	:	OLGA LIS
Credential	:	AUD
Telephone Number	:	719-333-1394

Provider Enumeration Date	:	05/15/2018
Last Update Date	:	06/16/2018

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