Provider Demographics
NPI:1316134802
Name:ECKHARDT, SUZANNE MARY (CP)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:MARY
Last Name:ECKHARDT
Suffix:
Gender:F
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 LUCAS AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-1912
Mailing Address - Country:US
Mailing Address - Phone:213-482-5226
Mailing Address - Fax:213-482-5040
Practice Address - Street 1:637 LUCAS AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1912
Practice Address - Country:US
Practice Address - Phone:213-482-5226
Practice Address - Fax:213-482-5040
Is Sole Proprietor?:No
Enumeration Date:2007-09-27
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DECP001228224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGFC000250Medicaid
CAGFC000250Medicaid