Provider Demographics
NPI:1275005852
Name:AUDSLP DIAGNOSTIC AND REHABILITATION CLINIC
Entity Type:Organization
Organization Name:AUDSLP DIAGNOSTIC AND REHABILITATION CLINIC
Other - Org Name:AUDSLP DIAGNOSTIC AND REHABILITATION CLINIC 2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NORMA
Authorized Official - Middle Name:IRIS
Authorized Official - Last Name:CARBAJAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:551-202-4929
Mailing Address - Street 1:1 BROADWAY STE 302
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07407-1845
Mailing Address - Country:US
Mailing Address - Phone:201-773-8962
Mailing Address - Fax:201-773-8963
Practice Address - Street 1:1 BROADWAY STE 302
Practice Address - Street 2:
Practice Address - City:ELMWOOD PARK
Practice Address - State:NJ
Practice Address - Zip Code:07407-1845
Practice Address - Country:US
Practice Address - Phone:201-773-8962
Practice Address - Fax:201-773-8963
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-12-20
Last Update Date:2022-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1851535934OtherNPI