Provider Demographics
NPI:1730739848
Name:EDDINS, WESLEY (OWNER)
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:
Last Name:EDDINS
Suffix:
Gender:M
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 GRAVENHURST CIR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-8660
Mailing Address - Country:US
Mailing Address - Phone:757-202-9863
Mailing Address - Fax:757-965-9777
Practice Address - Street 1:1308 GRAVENHURST CIR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-8660
Practice Address - Country:US
Practice Address - Phone:423-930-3978
Practice Address - Fax:757-965-9777
Is Sole Proprietor?:No
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN83751657172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
5150OtherAMBULATORY