Provider Demographics
NPI:1023693579
Name:LATIMER, EDDIE
Entity type:Individual
Prefix:
First Name:EDDIE
Middle Name:
Last Name:LATIMER
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 1:1104 1/2 E 7TH ST # 217
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90021-1504
Mailing Address - Country:US
Mailing Address - Phone:310-439-8421
Mailing Address - Fax:
Practice Address - Street 1:13790 ROCKPORT CT
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-6002
Practice Address - Country:US
Practice Address - Phone:310-920-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15101474374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide