Provider Demographics
NPI:1376285767
Name:BALTAZAR, ELDRIDGE E (L/ATC)
Entity Type:Individual
Prefix:MR
First Name:ELDRIDGE
Middle Name:E
Last Name:BALTAZAR
Suffix:
Gender:M
Credentials:L/ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 STOBHILL LN
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540-7243
Mailing Address - Country:US
Mailing Address - Phone:910-297-2115
Mailing Address - Fax:
Practice Address - Street 1:2416 KEERANS ST 82ND 3BCT
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-7243
Practice Address - Country:US
Practice Address - Phone:910-984-9119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-07
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23972255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty