Provider Demographics
NPI:1780740423
Name:EDWARDS, STACY KENTON (DC)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:KENTON
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:PO BOX 957
Mailing Address - Street 2:130 N. BROADWAY SUITE #1
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403
Mailing Address - Country:US
Mailing Address - Phone:859-986-9477
Mailing Address - Fax:859-985-7876
Practice Address - Street 1:130 N. BROADWAY, SUITE #1
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403
Practice Address - Country:US
Practice Address - Phone:859-986-9477
Practice Address - Fax:859-985-7876
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4066111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000069105OtherBCBS
KY000000069105OtherBCBS