Healthcare Provider Details

I. General information

NPI: 1336350396
Provider Name (Legal Business Name): ERIC CLAY SUWYN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5051 RODEO RD
LOS ANGELES CA
90016-4790
US

IV. Provider business mailing address

15530 W MAUNA LOA LN
SURPRISE AZ
85379-6278
US

V. Phone/Fax

Practice location:
  • Phone: 323-292-2202
  • Fax: 323-292-2552
Mailing address:
  • Phone: 805-302-9955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: