Provider Demographics
NPI:1760503221
Name:EDGE PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:EDGE PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:EVAN
Authorized Official - Last Name:SHUEY
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:909-831-6867
Mailing Address - Street 1:14 DOLORES CT
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-5567
Mailing Address - Country:US
Mailing Address - Phone:951-665-1510
Mailing Address - Fax:951-665-1515
Practice Address - Street 1:1695 S SAN JACINTO ST
Practice Address - Street 2:STE C
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583
Practice Address - Country:US
Practice Address - Phone:951-665-1510
Practice Address - Fax:951-665-1515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy