Healthcare Provider Details

I. General information

NPI: 1467134965
Provider Name (Legal Business Name): EON FAWCETT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2023
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25701 N LAKELAND BLVD STE 403
EUCLID OH
44132-2453
US

IV. Provider business mailing address

25701 N LAKELAND BLVD STE 403
EUCLID OH
44132-2453
US

V. Phone/Fax

Practice location:
  • Phone: 949-500-3155
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberTU717001
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: