Provider Demographics
NPI:1083940415
Name:AUDIOLOGY BALANCE DIAGNOSTIC P.C.
Entity Type:Organization
Organization Name:AUDIOLOGY BALANCE DIAGNOSTIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AU.D.
Authorized Official - Prefix:MS
Authorized Official - First Name:OLESIA
Authorized Official - Middle Name:
Authorized Official - Last Name:IVANUTENKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-801-6984
Mailing Address - Street 1:50 BRIGHTON 1ST RD
Mailing Address - Street 2:15L
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 BRIGHTON 1ST RD
Practice Address - Street 2:15L
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235
Practice Address - Country:US
Practice Address - Phone:732-801-6984
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002270231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty