Provider Demographics
NPI:1073016473
Name:EDER, COLLEEN B
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:B
Last Name:EDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14222-1809
Mailing Address - Country:US
Mailing Address - Phone:716-574-6540
Mailing Address - Fax:
Practice Address - Street 1:4540 SOUTHWESTERN BLVD
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-1930
Practice Address - Country:US
Practice Address - Phone:716-646-0096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-12
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00722900133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered