Provider Demographics
NPI:1689914749
Name:DAIGLE, ELRIDGE JR
Entity Type:Individual
Prefix:
First Name:ELRIDGE
Middle Name:
Last Name:DAIGLE
Suffix:JR
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 1:10507 SEDGEBROOK DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-8701
Mailing Address - Country:US
Mailing Address - Phone:813-672-3880
Mailing Address - Fax:
Practice Address - Street 1:10507 SEDGEBROOK DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-8701
Practice Address - Country:US
Practice Address - Phone:813-672-3880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-26
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906187311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL143044100Medicaid