Provider Demographics
NPI:1225145071
Name:SANDRETTO HEARING AID CENTER, LLC
Entity Type:Organization
Organization Name:SANDRETTO HEARING AID CENTER, LLC
Other - Org Name:EDW J SANDRETTO HEARING AID CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:JOHANSON
Authorized Official - Suffix:
Authorized Official - Credentials:HEARING AID DISPENSE
Authorized Official - Phone:408-269-4636
Mailing Address - Street 1:1635 MERIDIAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125
Mailing Address - Country:US
Mailing Address - Phone:408-269-4636
Mailing Address - Fax:408-269-4636
Practice Address - Street 1:1635 MERIDIAN AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125
Practice Address - Country:US
Practice Address - Phone:408-269-4636
Practice Address - Fax:408-269-4636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA2548237600000X
CAHA313237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ32369ZMedicaid
CAZZZ32369ZMedicaid