Provider Demographics
NPI:1922435833
Name:EDNIE, RAYMOND V (PT, DPT)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:V
Last Name:EDNIE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:760-633-6507
Mailing Address - Fax:760-633-7348
Practice Address - Street 1:71 GENTRY DR
Practice Address - Street 2:
Practice Address - City:FAIR HAVEN
Practice Address - State:NJ
Practice Address - Zip Code:07704-3439
Practice Address - Country:US
Practice Address - Phone:908-601-2862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-09
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01369500225100000X
CA298918225100000X
NY036902-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist