Basic Information
| Provider Information | |||||||||
| NPI: | 1073815999 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EATON | ||||||||
| FirstName: | WENDY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | CFTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3700 BRAINERD RD | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374113603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236970057 | ||||||||
| FaxNumber: | 4236489366 | ||||||||
| Practice Location | |||||||||
| Address1: | 2150 N OCOEE ST | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373113936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4235590013 | ||||||||
| FaxNumber: | 4235592442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2010 | ||||||||
| LastUpdateDate: | 11/29/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225000000X | CFTS1106 | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Orthotic Fitter |
ID Information
| ID | Type | State | Issuer | Description | 1507472 | 05 | TN | MEDICAID | 000973794E | 05 | GA | MEDICAID | 1455062 | 05 | TN | MEDICAID | 000973794C | 05 | GA | MEDICAID | 000973794D | 05 | GA | MEDICAID |