Provider Demographics
NPI:1790801801
Name:PROVIDENCE AUDIOLOGY
Entity Type:Organization
Organization Name:PROVIDENCE AUDIOLOGY
Other - Org Name:SEATTLE HEARING AND BALANCE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:AUD, FAAA
Authorized Official - Phone:206-320-5687
Mailing Address - Street 1:1600 E JEFFERSON ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-5698
Mailing Address - Country:US
Mailing Address - Phone:206-320-5687
Mailing Address - Fax:206-320-8145
Practice Address - Street 1:1600 E JEFFERSON ST
Practice Address - Street 2:SUITE 202
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-5698
Practice Address - Country:US
Practice Address - Phone:206-320-5687
Practice Address - Fax:206-320-8145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALD00001067174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty