Provider Demographics
NPI:1609437300
Name:WADDLE, EDDIE DEMICHAEL
Entity Type:Individual
Prefix:
First Name:EDDIE
Middle Name:DEMICHAEL
Last Name:WADDLE
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 1:1243 MAGNOLIA DALE DR
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:TX
Mailing Address - Zip Code:77545-9681
Mailing Address - Country:US
Mailing Address - Phone:832-880-4629
Mailing Address - Fax:281-972-9544
Practice Address - Street 1:16707 SONATA CT
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77053-5023
Practice Address - Country:US
Practice Address - Phone:832-880-4629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX01134881Medicaid