Healthcare Provider Details

I. General information

NPI: 1760032791
Provider Name (Legal Business Name): EDIKA WITHINGHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2019
Last Update Date: 09/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3148 BELVEDERE DR
RIVERSIDE CA
92507-3205
US

IV. Provider business mailing address

16075 GERANIUM CT
MORENO VALLEY CA
92551-7293
US

V. Phone/Fax

Practice location:
  • Phone: 951-788-0940
  • Fax:
Mailing address:
  • Phone: 951-345-2646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: