Basic Information
| Provider Information | |||||||||
| NPI: | 1215330071 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EIDENS | ||||||||
| FirstName: | FEDGERIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 PARK AVE APT 5 | ||||||||
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| City: | DAVIDSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280365552 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 320 PARK AVE APT 5 | ||||||||
| Address2: | |||||||||
| City: | DAVIDSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280365552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046365812 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2014 | ||||||||
| LastUpdateDate: | 10/07/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 583 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 261QP2000X | 583 | NC | N | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.