Provider Demographics
NPI:1598393092
Name:EADDIE, EBONY MONIQUE
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:MONIQUE
Last Name:EADDIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3523 WOODRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44121-1533
Mailing Address - Country:US
Mailing Address - Phone:216-203-7387
Mailing Address - Fax:
Practice Address - Street 1:3523 WOODRIDGE RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44121-1533
Practice Address - Country:US
Practice Address - Phone:216-203-7387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-30
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH06-7636311ZA0620X
343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home