Provider Demographics
NPI:1013425016
Name:EDMOND, JAMES WILLIE JR
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:WILLIE
Last Name:EDMOND
Suffix:JR
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:PO BOX 96603
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77213-6603
Mailing Address - Country:US
Mailing Address - Phone:832-216-1007
Mailing Address - Fax:
Practice Address - Street 1:7109 JOHN RALSTON RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77044-2621
Practice Address - Country:US
Practice Address - Phone:832-216-1007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-12
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81-2775843Medicaid