Healthcare Provider Details

I. General information

NPI: 1124207642
Provider Name (Legal Business Name): EDITO AYSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2007
Last Update Date: 11/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HILLMONT AVE
VENTURA CA
93003-1647
US

IV. Provider business mailing address

3520 TERRACE DR
OXNARD CA
93033-6600
US

V. Phone/Fax

Practice location:
  • Phone: 805-652-6729
  • Fax:
Mailing address:
  • Phone: 805-986-4460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number512534
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: