Provider Demographics
NPI:1750712840
Name:VELASCO, EDWARD
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:VELASCO
Suffix:
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 1:4630 MCNICHOL AVE
Mailing Address - Street 2:
Mailing Address - City:OSCODA
Mailing Address - State:MI
Mailing Address - Zip Code:48750-1512
Mailing Address - Country:US
Mailing Address - Phone:989-739-3722
Mailing Address - Fax:
Practice Address - Street 1:400 NORTH ST W
Practice Address - Street 2:
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763-9161
Practice Address - Country:US
Practice Address - Phone:989-362-8647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-27
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3501011383225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist