Provider Demographics
NPI:1245221399
Name:EDWARDS CHIROPRACTIC PA
Entity Type:Organization
Organization Name:EDWARDS CHIROPRACTIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF PA
Authorized Official - Prefix:
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:904-389-0667
Mailing Address - Street 1:4558 SAN JUAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-2051
Mailing Address - Country:US
Mailing Address - Phone:904-389-0667
Mailing Address - Fax:904-389-5871
Practice Address - Street 1:4558 SAN JUAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-2051
Practice Address - Country:US
Practice Address - Phone:904-389-0667
Practice Address - Fax:904-389-5871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
89148Medicare ID - Type Unspecified
T56108Medicare UPIN