Provider Demographics
NPI:1407979479
Name:AUDIOLOGY ASSOCIATES OF SALT LAKE CITY, INC.
Entity Type:Organization
Organization Name:AUDIOLOGY ASSOCIATES OF SALT LAKE CITY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:REX
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-A
Authorized Official - Phone:801-302-8022
Mailing Address - Street 1:10441 S REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-8502
Mailing Address - Country:US
Mailing Address - Phone:801-302-8022
Mailing Address - Fax:
Practice Address - Street 1:10441 S REDWOOD RD
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-8502
Practice Address - Country:US
Practice Address - Phone:801-302-8022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT100046-4101231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT52850418401001OtherBLUE CROSS BLUE SHIELS
UT528504184003Medicaid
UT52850418401001OtherBLUE CROSS BLUE SHIELS
UT528504184003Medicaid