=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023693579
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDDIE LATIMER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2021
-----------------------------------------------------
Last Update Date | 03/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13790 ROCKPORT CT
-----------------------------------------------------
City | MORENO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92553-6002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-920-3400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1104 1/2 E 7TH ST # 217
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90021-1504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-439-8421
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number | 15101474
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------