Provider Demographics
NPI:1124492574
Name:DEMIAN, EDIDIA F
Entity type:Individual
Prefix:
First Name:EDIDIA
Middle Name:F
Last Name:DEMIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8440 EDGECLIFF CT
Mailing Address - Street 2:
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95610-0842
Mailing Address - Country:US
Mailing Address - Phone:916-753-6430
Mailing Address - Fax:916-560-3801
Practice Address - Street 1:8440 EDGECLIFF CT
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95610-0842
Practice Address - Country:US
Practice Address - Phone:916-753-6430
Practice Address - Fax:916-560-3801
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-23
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA347002299310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility