Provider Demographics
NPI:1073850103
Name:EDET, SAM (DC)
Entity Type:Individual
Prefix:MR
First Name:SAM
Middle Name:
Last Name:EDET
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10101 FONDREN RD STE 510
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77096-5144
Mailing Address - Country:US
Mailing Address - Phone:713-774-0477
Mailing Address - Fax:713-774-0478
Practice Address - Street 1:10101 FONDREN RD STE 510
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77096-5144
Practice Address - Country:US
Practice Address - Phone:713-774-0477
Practice Address - Fax:713-774-0478
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-09
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5616111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor