MEDICARE: MR. ROBERT FAILLACE AUD, CCC/A

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	AU1380	CA
2	231H00000X	Audiologist	AU1380	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AU0013800	OTHER	CA	BLUE SHIELD
2	AU1380	OTHER	CA	BLUE CROSS

General Provider Information

NPI Number	:	1417971110
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT FAILLACE AUD, CCC/A

Provider Business Mailing Address
First Line	:	3590 CAMINO DEL RIO N
Second Line	:	SUITE# 201
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-1707
Country	:	US
Telephone Number	:	619-810-1204
Fax Number	:	619-517-3233

Provider Business Practice Location Address
First Line	:	3590 CAMINO DEL RIO N
Second Line	:	SUITE# 201
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-1707
Country	:	US
Telephone Number	:	619-810-1204
Fax Number	:

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

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	12/03/2024

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