Provider Demographics
NPI:1912043969
Name:EIDAL, SUSANNE AF (DPT)
Entity Type:Individual
Prefix:MRS
First Name:SUSANNE
Middle Name:AF
Last Name:EIDAL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MRS
Other - First Name:SUSANNE
Other - Middle Name:ASAKO FUKAGAWA
Other - Last Name:EIDAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:2251 COUNTRY CLUB LN
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:CA
Mailing Address - Zip Code:93662-3859
Mailing Address - Country:US
Mailing Address - Phone:559-819-8696
Mailing Address - Fax:559-819-8921
Practice Address - Street 1:2251 COUNTRY CLUB LN
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:CA
Practice Address - Zip Code:93662-3859
Practice Address - Country:US
Practice Address - Phone:559-819-8696
Practice Address - Fax:559-819-8921
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32571225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACK710Medicare UPIN