MEDICARE: VALLEY AUDIOLOGY PROFESSIONAL CORPORATION

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	237600000X	Audiologist-Hearing Aid Fitter	AU 2727	CA
2	231H00000X	Audiologist	AU 2727	CA

General Provider Information

NPI Number	:	1396004172
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VALLEY AUDIOLOGY PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	PMB 358
Second Line	:	4719 QUAIL LAKES DRIVE SUITE G
City	:	STOCKTON
State	:	CA
Zip	:	95207-5267
Country	:	US
Telephone Number	:	209-951-6491
Fax Number	:

Provider Business Practice Location Address
First Line	:	4623 QUAIL LAKES DRIVE
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95207-5258
Country	:	US
Telephone Number	:	209-951-6491
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. CARISSA LAMORE
Credential	:
Telephone Number	:	209-951-6491

Provider Enumeration Date	:	05/14/2012
Last Update Date	:	05/14/2012

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