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General NPI Number Information
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NPI Number | 1972963973
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Entity Type | Individual
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Provider Name | EUSTACE EDMEAD
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Gender | Male
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Dates
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Enumeration Date | 03/03/2016
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Last Update Date | 03/03/2016
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Provider Practice Location Address
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Address Line | 97-20 VAN WYCK EXPWY APT D5
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City | SOUTH RICHMOND HILL
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State | NY
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Zip | 11419
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Country | US
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Telephone | 718-739-4184
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Fax |
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Provider Business Mailing Address
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Address Line | 9720 VAN WYCK EXPY APT D5
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City | SOUTH RICHMOND HILL
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State | NY
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Zip | 11419-2370
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number |
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License Number State |
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