Provider Demographics
NPI:1740787639
Name:VALENZUELA, EDER
Entity Type:Individual
Prefix:
First Name:EDER
Middle Name:
Last Name:VALENZUELA
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 1:8537 SUSSEX CT
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76108-2729
Mailing Address - Country:US
Mailing Address - Phone:817-600-2752
Mailing Address - Fax:
Practice Address - Street 1:8537 SUSSEX CT
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76108-2729
Practice Address - Country:US
Practice Address - Phone:817-600-2752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX331388164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse