Provider Demographics
NPI:1801053046
Name:TRI STATE AUDIOLOGY & VESTIBULAR CENTER
Entity type:Organization
Organization Name:TRI STATE AUDIOLOGY & VESTIBULAR CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:928-758-3337
Mailing Address - Street 1:1370 RAMAR RD
Mailing Address - Street 2:SUIE D
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-7117
Mailing Address - Country:US
Mailing Address - Phone:928-758-3337
Mailing Address - Fax:928-758-4404
Practice Address - Street 1:1677 QUARTZ CIR
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-6016
Practice Address - Country:US
Practice Address - Phone:928-758-9130
Practice Address - Fax:928-758-4404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDA4586332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment