Provider Demographics
NPI:1144749581
Name:EDWARDS, DAMIAN ALFONSO (CASE 1)
Entity Type:Individual
Prefix:
First Name:DAMIAN
Middle Name:ALFONSO
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:CASE 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 D ST
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-3719
Mailing Address - Country:US
Mailing Address - Phone:145-454-4404
Mailing Address - Fax:415-454-4864
Practice Address - Street 1:603 D ST
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3719
Practice Address - Country:US
Practice Address - Phone:145-454-4404
Practice Address - Fax:415-454-4864
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator