Healthcare Provider Details

I. General information

NPI: 1861055758
Provider Name (Legal Business Name): EDDIE RAUL GARCIA ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2019
Last Update Date: 01/21/2020
Certification Date: 01/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1365 NE BRANDI WAY APT B102
PULLMAN WA
99163-5309
US

IV. Provider business mailing address

1365 NE BRANDI WAY APT B102
PULLMAN WA
99163-5309
US

V. Phone/Fax

Practice location:
  • Phone: 425-970-5682
  • Fax:
Mailing address:
  • Phone: 425-970-5682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberA160971718
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: