Provider Demographics
NPI:1861604902
Name:EOTI
Entity type:Organization
Organization Name:EOTI
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:OWEN
Authorized Official - Last Name:TERINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-495-1043
Mailing Address - Street 1:327 S MOORPARK RD
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91361-1008
Mailing Address - Country:US
Mailing Address - Phone:805-495-1043
Mailing Address - Fax:
Practice Address - Street 1:327 S MOORPARK RD
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91361-1008
Practice Address - Country:US
Practice Address - Phone:805-495-1043
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG014784261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center