Provider Demographics
NPI:1104308378
Name:PALLAIS, MARIO HUMBERTO (HIS)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:HUMBERTO
Last Name:PALLAIS
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27201 TOURNEY RD STE 123
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-1801
Mailing Address - Country:US
Mailing Address - Phone:661-952-7912
Mailing Address - Fax:
Practice Address - Street 1:27201 TOURNEY RD STE 123
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-1801
Practice Address - Country:US
Practice Address - Phone:661-952-7912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8384237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8384OtherHEARING AID DISPENSER