Healthcare Provider Details

I. General information

NPI: 1972078517
Provider Name (Legal Business Name): ERIC SHAVER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2018
Last Update Date: 10/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 W PINE ST
ORLANDO FL
32801-2610
US

IV. Provider business mailing address

35 W PINE ST STE 218
ORLANDO FL
32801-2656
US

V. Phone/Fax

Practice location:
  • Phone: 321-315-3601
  • Fax:
Mailing address:
  • Phone: 321-315-3601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License NumberRN9246384
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: