Provider Demographics
NPI:1952575458
Name:BURBANK HEARING CLINIC A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:BURBANK HEARING CLINIC A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / DIRECTOR / AUDIOLOGIST
Authorized Official - Prefix:MR
Authorized Official - First Name:COURTLANDT
Authorized Official - Middle Name:C
Authorized Official - Last Name:WARNER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-A
Authorized Official - Phone:818-842-4069
Mailing Address - Street 1:127 N SAN FERNANDO BLVD
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502-1208
Mailing Address - Country:US
Mailing Address - Phone:818-842-4069
Mailing Address - Fax:818-848-1616
Practice Address - Street 1:127 N SAN FERNANDO BLVD
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91502-1208
Practice Address - Country:US
Practice Address - Phone:818-842-4069
Practice Address - Fax:818-848-1616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU2077231H00000X
CAHA2679237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHA0026790Medicaid
CAHA0026790Medicaid