Provider Demographics
NPI:1972833481
Name:EASTERN IDAHO AUDIOLOGY, LLC
Entity Type:Organization
Organization Name:EASTERN IDAHO AUDIOLOGY, LLC
Other - Org Name:POCATELLO HEARING ZONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/AUDIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:OLENICK
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:208-238-0020
Mailing Address - Street 1:7808 W POCATELLO CREEK RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-9058
Mailing Address - Country:US
Mailing Address - Phone:208-235-1544
Mailing Address - Fax:208-238-0021
Practice Address - Street 1:4155 YELLOWSTONE AVE
Practice Address - Street 2:PINE RIDGE MALL
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2345
Practice Address - Country:US
Practice Address - Phone:208-238-0020
Practice Address - Fax:208-238-0021
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EASTERN IDAHO AUDIOLOGY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-05
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAUD1214237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Single Specialty