Provider Demographics
NPI:1912140815
Name:MODESTO HEARING AID CENTER
Entity Type:Organization
Organization Name:MODESTO HEARING AID CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERASA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DAFFRON
Authorized Official - Suffix:
Authorized Official - Credentials:HEARING AID DISPENSE
Authorized Official - Phone:209-577-1014
Mailing Address - Street 1:611 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-6156
Mailing Address - Country:US
Mailing Address - Phone:209-577-1014
Mailing Address - Fax:209-577-8046
Practice Address - Street 1:611 SCENIC DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-6156
Practice Address - Country:US
Practice Address - Phone:209-577-1014
Practice Address - Fax:209-577-8046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-08
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA5008332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0216438Medicaid