MEDICARE: DESTINY BROADEN AUD

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	231H00000X	Audiologist	A2181	NV

General Provider Information

NPI Number	:	1245743509
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTINY BROADEN AUD

Provider Business Mailing Address
First Line	:	5815 NUEVO LEON ST UNIT 7
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-4100
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	98 E LAKE MEAD PKWY STE 105
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89015-6443
Country	:	US
Telephone Number	:	702-861-1183
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2017
Last Update Date	:	01/18/2021

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Directions to “ DESTINY BROADEN AUD” Practice Location

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