Provider Demographics
NPI:1225598618
Name:MAESTAS, EDDIE G
Entity Type:Individual
Prefix:
First Name:EDDIE
Middle Name:G
Last Name:MAESTAS
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 1:360 CHURCH ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3796
Mailing Address - Country:US
Mailing Address - Phone:503-373-3819
Mailing Address - Fax:
Practice Address - Street 1:360 CHURCH ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3796
Practice Address - Country:US
Practice Address - Phone:503-373-3819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator