Provider Demographics
NPI:1770539694
Name:COMPLETE CARE AUDIOLOGY INC.
Entity type:Organization
Organization Name:COMPLETE CARE AUDIOLOGY INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BREK
Authorized Official - Middle Name:D
Authorized Official - Last Name:STOKER
Authorized Official - Suffix:
Authorized Official - Credentials:AUD CCCA
Authorized Official - Phone:208-376-3591
Mailing Address - Street 1:13176 PERSIMMON LN
Mailing Address - Street 2:# 120
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1986
Mailing Address - Country:US
Mailing Address - Phone:208-376-3591
Mailing Address - Fax:208-376-3594
Practice Address - Street 1:13176 PERSIMMON LN
Practice Address - Street 2:# 120
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1986
Practice Address - Country:US
Practice Address - Phone:208-376-3591
Practice Address - Fax:208-376-3594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDH412231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010143633OtherBLUE SHIELD OF IDAHO
IDAU191OtherBLUE CROSS