Provider Demographics
NPI:1083077622
Name:MAXWELL, ERIC SHANE
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:SHANE
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 BERKSHIRE RD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2439
Mailing Address - Country:US
Mailing Address - Phone:386-255-3418
Mailing Address - Fax:
Practice Address - Street 1:565 BERKSHIRE RD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2439
Practice Address - Country:US
Practice Address - Phone:386-255-3418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider