Provider Demographics
NPI:1255674057
Name:EADDY, ALBERT
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:
Last Name:EADDY
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 1:4841 JESSIE AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-8662
Mailing Address - Country:US
Mailing Address - Phone:619-672-7439
Mailing Address - Fax:
Practice Address - Street 1:4841 JESSIE AVE APT 8
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-8662
Practice Address - Country:US
Practice Address - Phone:619-672-7439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-29
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2012031347172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver