Healthcare Provider Details

I. General information

NPI: 1174197594
Provider Name (Legal Business Name): ALEXANDER JORDAN EADES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2021
Last Update Date: 05/19/2021
Certification Date: 05/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 N TYNDALL PKWY
PANAMA CITY FL
32404-9407
US

IV. Provider business mailing address

110 N MARIE DR
PANAMA CITY FL
32401-4053
US

V. Phone/Fax

Practice location:
  • Phone: 850-866-0441
  • Fax:
Mailing address:
  • Phone: 850-851-7716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number21151406
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: