Healthcare Provider Details

I. General information

NPI: 1255674057
Provider Name (Legal Business Name): ALBERT EADDY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2013
Last Update Date: 03/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4841 JESSIE AVE APT 8
LA MESA CA
91942-8662
US

IV. Provider business mailing address

4841 JESSIE AVE APT 8
LA MESA CA
91942-8662
US

V. Phone/Fax

Practice location:
  • Phone: 619-672-7439
  • Fax:
Mailing address:
  • Phone: 619-672-7439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number2012031347
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: