Healthcare Provider Details

I. General information

NPI: 1720714959
Provider Name (Legal Business Name): EDDIE JAMES EADS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2022
Last Update Date: 07/29/2022
Certification Date: 07/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

753 TATE HOLLOW RD
CHARLESTON WV
25312-5369
US

IV. Provider business mailing address

753 TATE HOLLOW RD
CHARLESTON WV
25312-5369
US

V. Phone/Fax

Practice location:
  • Phone: 304-984-1852
  • Fax:
Mailing address:
  • Phone: 304-984-1852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: