Provider Demographics
NPI:1194369892
Name:EDWARDS, THEO
Entity Type:Individual
Prefix:
First Name:THEO
Middle Name:
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 1:207 N. HWY 59, KANSAS OK
Mailing Address - Street 2:
Mailing Address - City:KANSAS
Mailing Address - State:OK
Mailing Address - Zip Code:74347-0000
Mailing Address - Country:US
Mailing Address - Phone:918-786-4434
Mailing Address - Fax:
Practice Address - Street 1:211 N HIGHWAY 59
Practice Address - Street 2:
Practice Address - City:KANSAS
Practice Address - State:OK
Practice Address - Zip Code:74347-7076
Practice Address - Country:US
Practice Address - Phone:918-786-4434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator