Provider Demographics
NPI:1477797082
Name:MENDOCINO LAKE AUDIOLOGY INC.
Entity Type:Organization
Organization Name:MENDOCINO LAKE AUDIOLOGY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:HUBERT
Authorized Official - Middle Name:R
Authorized Official - Last Name:FERNANDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-463-2966
Mailing Address - Street 1:756 S DORA ST
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-5336
Mailing Address - Country:US
Mailing Address - Phone:707-463-2966
Mailing Address - Fax:707-463-2970
Practice Address - Street 1:756 S DORA ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5336
Practice Address - Country:US
Practice Address - Phone:707-463-2966
Practice Address - Fax:707-463-2970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-27
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU1445237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Single Specialty