Provider Demographics
NPI:1508337049
Name:EDMUNDS, ROSS
Entity Type:Individual
Prefix:
First Name:ROSS
Middle Name:
Last Name:EDMUNDS
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 1:1084 N EL CAMINO REAL STE B351
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-1334
Mailing Address - Country:US
Mailing Address - Phone:760-918-9200
Mailing Address - Fax:
Practice Address - Street 1:2719 LOKER AVE W STE A
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92010-6679
Practice Address - Country:US
Practice Address - Phone:760-918-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA296065225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA296065OtherPHYSICAL THERAPY LICENSE