Provider Demographics
NPI:1619536711
Name:FUENTES, EDDIE
Entity Type:Individual
Prefix:
First Name:EDDIE
Middle Name:
Last Name:FUENTES
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 1:3321 BELL ST STE C
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-5023
Mailing Address - Country:US
Mailing Address - Phone:806-576-2389
Mailing Address - Fax:
Practice Address - Street 1:3321 BELL ST STE C
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-5023
Practice Address - Country:US
Practice Address - Phone:806-576-2389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX225B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225B00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPulmonary Function TechnologistGroup - Multi-Specialty