Provider Demographics
NPI:1093947103
Name:ALBINO, EDWIN DANTE (IDC)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:DANTE
Last Name:ALBINO
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12230 PAINTED TREE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-3851
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12230 PAINTED TREE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-3851
Practice Address - Country:US
Practice Address - Phone:980-939-4011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-23
Last Update Date:2009-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman