Provider Demographics
NPI:1548205313
Name:EDDIE ETTE
Entity Type:Organization
Organization Name:EDDIE ETTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-200-2363
Mailing Address - Street 1:705 E ABRAM ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76010-1240
Mailing Address - Country:US
Mailing Address - Phone:817-200-2363
Mailing Address - Fax:817-200-2356
Practice Address - Street 1:705 E ABRAM ST
Practice Address - Street 2:SUITE 100
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76010-1240
Practice Address - Country:US
Practice Address - Phone:817-200-2363
Practice Address - Fax:817-200-2356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX332B00000X332B00000X
TX0063143332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX158114202Medicaid
TX531655OtherBLUE CROSS NUMBER
TX158114201OtherMEDICAID CCP
TX17089399OtherEVERCARE
TX158114202Medicaid
TX4596650001Medicare PIN