Provider Demographics
NPI:1275958571
Name:BOLENBAUGH, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:BOLENBAUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 CALIFORNIA BLVD
Mailing Address - Street 2:SUITE F
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2542
Mailing Address - Country:US
Mailing Address - Phone:805-544-3277
Mailing Address - Fax:
Practice Address - Street 1:628 CALIFORNIA BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2542
Practice Address - Country:US
Practice Address - Phone:805-544-3277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-23
Last Update Date:2014-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA2571237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist