Provider Demographics
NPI:1356628622
Name:EDWARDS, BENJAMIN CLAYTON (DPT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:CLAYTON
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8419
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39535-8087
Mailing Address - Country:US
Mailing Address - Phone:662-294-1007
Mailing Address - Fax:662-294-1079
Practice Address - Street 1:1322C SUNSET DR
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-4000
Practice Address - Country:US
Practice Address - Phone:662-294-1007
Practice Address - Fax:662-294-1079
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-14
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT4886225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist