Provider Demographics
NPI:1184938375
Name:BODAK, EUNICE JENNY (HCPD)
Entity type:Individual
Prefix:MRS
First Name:EUNICE
Middle Name:JENNY
Last Name:BODAK
Suffix:
Gender:F
Credentials:HCPD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2750 ARTESIA BLVD UNIT 117
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-3392
Mailing Address - Country:US
Mailing Address - Phone:310-780-7697
Mailing Address - Fax:310-371-1249
Practice Address - Street 1:1220 5TH AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90019-3445
Practice Address - Country:US
Practice Address - Phone:310-780-7697
Practice Address - Fax:310-371-1249
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-30
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA522662372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA372600000XMedicaid