Provider Demographics
NPI:1336279157
Name:WEAVER, KENT E (AUD)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:E
Last Name:WEAVER
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26726 CROWN VALLEY PKWY
Mailing Address - Street 2:#210
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-8006
Mailing Address - Country:US
Mailing Address - Phone:959-364-4361
Mailing Address - Fax:949-364-7124
Practice Address - Street 1:26726 CROWN VALLEY PKWY
Practice Address - Street 2:#210
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-8006
Practice Address - Country:US
Practice Address - Phone:959-364-4361
Practice Address - Fax:949-364-7124
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00461231H00000X
IA00744237600000X
CAAU3093237600000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0262824Medicaid
IA0262824Medicaid