Provider Demographics
NPI:1639573629
Name:EDWARDS, GARRICK (AT,C)
Entity Type:Individual
Prefix:
First Name:GARRICK
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:AT,C
Other - Prefix:MR
Other - First Name:GARRICK
Other - Middle Name:JOHN
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AT,,C
Mailing Address - Street 1:1501 NE 62ND ST
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33334-5116
Mailing Address - Country:US
Mailing Address - Phone:954-776-2124
Mailing Address - Fax:
Practice Address - Street 1:1501 NE 62ND STREET
Practice Address - Street 2:
Practice Address - City:FT. LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33334
Practice Address - Country:US
Practice Address - Phone:954-776-2124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-20
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL1707174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator