Provider Demographics
NPI:1831588052
Name:LAND OF ENCHANTMENT AUDIOLOGY LLC
Entity type:Organization
Organization Name:LAND OF ENCHANTMENT AUDIOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUDIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TOBY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:505-807-9805
Mailing Address - Street 1:5901 WYOMING BLVD NE
Mailing Address - Street 2:STE J-124
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3838
Mailing Address - Country:US
Mailing Address - Phone:505-807-9805
Mailing Address - Fax:
Practice Address - Street 1:264 S CAMINO DEL PUEBLO
Practice Address - Street 2:BUILDING B
Practice Address - City:BERNALILLO
Practice Address - State:NM
Practice Address - Zip Code:87004-6070
Practice Address - Country:US
Practice Address - Phone:505-807-9805
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4526261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech