Provider Demographics
NPI:1043398514
Name:KOGLIN, DIANE (AUD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:KOGLIN
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 CAMELBACK RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29617-7335
Mailing Address - Country:US
Mailing Address - Phone:864-434-1228
Mailing Address - Fax:
Practice Address - Street 1:4 CAMELBACK RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29617-7335
Practice Address - Country:US
Practice Address - Phone:864-434-1228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000077237600000X
SC3930237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI54-0-C2-0269OtherBCBS/DISPENSING
MI64-0-C2-2601OtherBCBS/TESTING
SCQ373590281OtherMEDICARE
SC000000551641OtherBCBS
SCSA1394Medicaid