Provider Demographics
NPI:1720152341
Name:EDWARDS, DAVID KENNETH (DC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:KENNETH
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 CENTRAL AVE N
Mailing Address - Street 2:SUITE I
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-4374
Mailing Address - Country:US
Mailing Address - Phone:229-386-0227
Mailing Address - Fax:229-386-0360
Practice Address - Street 1:201 CENTRAL AVE N
Practice Address - Street 2:SUITE I
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-4374
Practice Address - Country:US
Practice Address - Phone:229-386-0227
Practice Address - Fax:229-386-0360
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002085111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00497923AMedicaid
GA00497923AMedicaid
GA35ZCBGKMedicare ID - Type UnspecifiedMEDICARE ID