Provider Demographics
NPI:1780104935
Name:EDWARDS, REGINA C
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:C
Last Name:EDWARDS
Suffix:
Gender:F
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 1086
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-9101
Mailing Address - Country:US
Mailing Address - Phone:804-276-6713
Mailing Address - Fax:804-271-4802
Practice Address - Street 1:10112 GROVE CREST CT
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23236-5531
Practice Address - Country:US
Practice Address - Phone:804-276-6713
Practice Address - Fax:804-271-4802
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-20
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities