Provider Demographics
NPI:1295784528
Name:ELDRIDGE, MARILYN
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:ELDRIDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W SANTA ANA BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-4134
Mailing Address - Country:US
Mailing Address - Phone:714-347-0390
Mailing Address - Fax:
Practice Address - Street 1:200 W SANTA ANA BLVD
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4134
Practice Address - Country:US
Practice Address - Phone:714-347-0390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9060225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist