Provider Demographics
NPI:1407212525
Name:FOREST LAKE AUDIOLOGY LLC
Entity Type:Organization
Organization Name:FOREST LAKE AUDIOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:AUDIOLOGIST
Authorized Official - Phone:803-888-7330
Mailing Address - Street 1:5301 N TRENHOLM RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29206-3226
Mailing Address - Country:US
Mailing Address - Phone:803-888-7330
Mailing Address - Fax:
Practice Address - Street 1:5301 N TRENHOLM RD
Practice Address - Street 2:SUITE A
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29206-3226
Practice Address - Country:US
Practice Address - Phone:803-888-7330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-05
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC3435231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty