Provider Demographics
NPI:1033683586
Name:EDWARDS, NATHANIEL MORGAN
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:MORGAN
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6214 W MANCHESTER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-3801
Mailing Address - Country:US
Mailing Address - Phone:310-348-8464
Mailing Address - Fax:310-348-8470
Practice Address - Street 1:6214 W MANCHESTER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3801
Practice Address - Country:US
Practice Address - Phone:310-348-8464
Practice Address - Fax:310-348-8464
Is Sole Proprietor?:No
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA295183225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist