Provider Demographics
NPI:1730600453
Name:FAIRCLOTH, IEDA SCHUMACHER (SA-C)
Entity type:Individual
Prefix:
First Name:IEDA
Middle Name:SCHUMACHER
Last Name:FAIRCLOTH
Suffix:
Gender:F
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4811 NW 103RD DR
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33076-1725
Mailing Address - Country:US
Mailing Address - Phone:954-270-9673
Mailing Address - Fax:
Practice Address - Street 1:4811 NW 103 DRIVE
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33076
Practice Address - Country:US
Practice Address - Phone:954-270-9673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16-717208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery