Provider Demographics
NPI:1326137233
Name:EDANO, ALLEN (PT)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:
Last Name:EDANO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5957 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77642-6204
Mailing Address - Country:US
Mailing Address - Phone:409-982-8878
Mailing Address - Fax:409-724-7871
Practice Address - Street 1:5957 9TH AVE
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642-6204
Practice Address - Country:US
Practice Address - Phone:409-982-8878
Practice Address - Fax:409-982-5119
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1116853225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2071672Medicaid
TX2071672Medicaid