Provider Demographics
NPI:1891828927
Name:BALLADA, EDWIN LU (DPT)
Entity Type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:LU
Last Name:BALLADA
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 1:411 W WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-4554
Mailing Address - Country:US
Mailing Address - Phone:352-357-3565
Mailing Address - Fax:
Practice Address - Street 1:411 W WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-4554
Practice Address - Country:US
Practice Address - Phone:352-357-3565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23177225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist