MEDICARE: MRS. JUDY A EIDE RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN074226	AZ

General Provider Information

NPI Number	:	1689877169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JUDY A EIDE RN

Provider Business Mailing Address
First Line	:	2200 HAVASUPAI BLVD
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-3798
Country	:	US
Telephone Number	:	928-505-6911
Fax Number	:	928-505-6991

Provider Business Practice Location Address
First Line	:	2675 S PALO VERDE BLVD
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-4919
Country	:	US
Telephone Number	:	928-505-9611
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2007
Last Update Date	:	07/08/2007

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