Provider Demographics
NPI:1730914458
Name:THACKER, ELOISE CATHERINE (C70773)
Entity type:Individual
Prefix:
First Name:ELOISE
Middle Name:CATHERINE
Last Name:THACKER
Suffix:
Gender:F
Credentials:C70773
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 E 21ST ST STE J
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-4851
Mailing Address - Country:US
Mailing Address - Phone:909-882-0193
Mailing Address - Fax:909-883-4834
Practice Address - Street 1:355 E 21ST ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4824
Practice Address - Country:US
Practice Address - Phone:909-882-0193
Practice Address - Fax:909-883-4834
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC70773332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies