Provider Demographics
NPI:1639304173
Name:FAIRFIELD, GLEN ERIC
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:ERIC
Last Name:FAIRFIELD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FILE #55745
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-5745
Mailing Address - Country:US
Mailing Address - Phone:561-478-8770
Mailing Address - Fax:561-688-8877
Practice Address - Street 1:160 N 9TH ST
Practice Address - Street 2:
Practice Address - City:GROVER BEACH
Practice Address - State:CA
Practice Address - Zip Code:93433-2122
Practice Address - Country:US
Practice Address - Phone:805-481-1523
Practice Address - Fax:805-481-1269
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2915237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist