Provider Demographics
NPI:1578547683
Name:EDDOW, JIM JIRO (PT, DPT, OCS)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:JIRO
Last Name:EDDOW
Suffix:
Gender:M
Credentials:PT, DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2815 S MAIN ST STE 205
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-2533
Mailing Address - Country:US
Mailing Address - Phone:951-475-1307
Mailing Address - Fax:951-475-1308
Practice Address - Street 1:2815 S MAIN ST STE 205
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882
Practice Address - Country:US
Practice Address - Phone:951-475-1307
Practice Address - Fax:951-475-1308
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291262251X0800X
CAPT29126225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT291261OtherMEDICARE PTAN
CA0PT291260OtherBLUE SHIELD OF CALIFORNIA