Provider Demographics
NPI:1003890229
Name:EDDOW, CHRISTINE MARIE (PT DPT OCS WCS CHT)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:MARIE
Last Name:EDDOW
Suffix:
Gender:F
Credentials:PT DPT OCS WCS CHT
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:MARIE
Other - Last Name:STARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:2815 S MAIN ST STE 205
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-2533
Mailing Address - Country:US
Mailing Address - Phone:951-475-1307
Mailing Address - Fax:951-475-1308
Practice Address - Street 1:2815 S MAIN ST
Practice Address - Street 2:STE. 205
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-2531
Practice Address - Country:US
Practice Address - Phone:951-475-1307
Practice Address - Fax:951-475-1308
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT17235225100000X, 2251H1200X
CA172352251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA160497Medicare PIN