Provider Demographics
NPI:1427232461
Name:SEVIDAL, ERIC JOSEPH SUPNET
Entity Type:Individual
Prefix:
First Name:ERIC JOSEPH
Middle Name:SUPNET
Last Name:SEVIDAL
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 1:172 MANZANITA PL
Mailing Address - Street 2:
Mailing Address - City:HERCULES
Mailing Address - State:CA
Mailing Address - Zip Code:94547-1161
Mailing Address - Country:US
Mailing Address - Phone:510-245-1252
Mailing Address - Fax:
Practice Address - Street 1:3290 EXECUTIVE CENTER II
Practice Address - Street 2:CAMBRIDGE HEALTHCARE NORTH RIDGE
Practice Address - City:ELLICOTT
Practice Address - State:MD
Practice Address - Zip Code:21043
Practice Address - Country:US
Practice Address - Phone:410-750-9006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist