Healthcare Provider Details

I. General information

NPI: 1962881151
Provider Name (Legal Business Name): EDDIE JAYSON GUZMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2015
Last Update Date: 05/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10309 SCULPIN ST
SAN DIEGO CA
92124-3669
US

IV. Provider business mailing address

10309 SCULPIN ST
SAN DIEGO CA
92124-3669
US

V. Phone/Fax

Practice location:
  • Phone: 469-774-3423
  • Fax:
Mailing address:
  • Phone: 469-774-3423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: