Provider Demographics
NPI:1417971110
Name:FAILLACE, ROBERT (AUD, CCC/A)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:FAILLACE
Suffix:
Gender:M
Credentials:AUD, CCC/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3590 CAMINO DEL RIO N
Mailing Address - Street 2:SUITE# 201
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-1707
Mailing Address - Country:US
Mailing Address - Phone:619-810-1204
Mailing Address - Fax:
Practice Address - Street 1:3590 CAMINO DEL RIO N
Practice Address - Street 2:SUITE# 201
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1707
Practice Address - Country:US
Practice Address - Phone:619-810-1204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU1380231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU0013800OtherBLUE SHIELD
CAAU1380OtherBLUE CROSS
CAWAU1380DMedicare ID - Type Unspecified