Provider Demographics
NPI:1144385998
Name:NEWPORT MESA AUDIOLOGY INC
Entity Type:Organization
Organization Name:NEWPORT MESA AUDIOLOGY INC
Other - Org Name:NEWPORT MESA AUDIOLOGY BALANCE AND EAR INSTITUTE INC
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:MANGO
Authorized Official - Suffix:
Authorized Official - Credentials:AUD PHD
Authorized Official - Phone:949-642-7935
Mailing Address - Street 1:500 OLD NEWPORT BOULEVARD
Mailing Address - Street 2:STE 101
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663
Mailing Address - Country:US
Mailing Address - Phone:949-642-7935
Mailing Address - Fax:949-642-2950
Practice Address - Street 1:500 OLD NEWPORT BOULEVARD
Practice Address - Street 2:STE 101
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663
Practice Address - Country:US
Practice Address - Phone:949-642-7935
Practice Address - Fax:949-642-2950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAUD379237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHA1235OtherHEARING DESPENSING LIC#
CAAUD0003790Medicaid
CAAUD0003790Medicaid