Provider Demographics
NPI: | 1073815999 |
---|---|
Name: | EATON, WENDY D (CFTS) |
Entity Type: | Individual |
Prefix: | |
First Name: | WENDY |
Middle Name: | D |
Last Name: | EATON |
Suffix: | |
Gender: | F |
Credentials: | CFTS |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 3700 BRAINERD RD |
Mailing Address - Street 2: | |
Mailing Address - City: | CHATTANOOGA |
Mailing Address - State: | TN |
Mailing Address - Zip Code: | 37411-3603 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 423-697-0057 |
Mailing Address - Fax: | 423-648-9366 |
Practice Address - Street 1: | 2150 N OCOEE ST |
Practice Address - Street 2: | |
Practice Address - City: | CLEVELAND |
Practice Address - State: | TN |
Practice Address - Zip Code: | 37311-3936 |
Practice Address - Country: | US |
Practice Address - Phone: | 423-559-0013 |
Practice Address - Fax: | 423-559-2442 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2010-11-29 |
Last Update Date: | 2010-11-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CFTS1106 | 225000000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 225000000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Orthotic Fitter |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TN | 1507472 | Medicaid | |
GA | 000973794E | Medicaid | |
TN | 1455062 | Medicaid | |
GA | 000973794C | Medicaid | |
GA | 000973794D | Medicaid | |
1254770003 | Medicare NSC | ||
1254770002 | Medicare NSC |