MEDICARE: ROBERT EDDY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	OTA12852	FL

General Provider Information

NPI Number	:	1700206547
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT EDDY

Provider Business Mailing Address
First Line	:	3 ZERINGTON CT
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32164-5235
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1055 3RD ST
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32117-4101
Country	:	US
Telephone Number	:	386-252-3686
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/20/2014
Last Update Date	:	04/20/2014

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