Provider Demographics
NPI:1538525274
Name:THE SPEECH LAB INCOPORATED
Entity type:Organization
Organization Name:THE SPEECH LAB INCOPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:MR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:COYLE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:714-580-4888
Mailing Address - Street 1:1132 BUCKINGHAM DR
Mailing Address - Street 2:APARTMENT B
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-2129
Mailing Address - Country:US
Mailing Address - Phone:714-580-4888
Mailing Address - Fax:
Practice Address - Street 1:2900 BRISTOL ST STE E203
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-7908
Practice Address - Country:US
Practice Address - Phone:714-580-4888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-11
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation