Healthcare Provider Details

I. General information

NPI: 1487055117
Provider Name (Legal Business Name): ELIZA RUPP IDMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2014
Last Update Date: 09/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 ASBURY AVE
DOVER DE
19901-5503
US

IV. Provider business mailing address

4102 PINION DR
USAF ACADEMY CO
80840-2502
US

V. Phone/Fax

Practice location:
  • Phone: 302-233-3290
  • Fax:
Mailing address:
  • Phone: 719-333-5111
  • 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: