Provider Demographics
NPI:1811313810
Name:EDWARDS, RICHARD
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:EDWARDS
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 1:234 SE AMMONS AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:FL
Mailing Address - Zip Code:32340-3091
Mailing Address - Country:US
Mailing Address - Phone:850-673-9897
Mailing Address - Fax:850-973-6663
Practice Address - Street 1:234 SE AMMONS AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:FL
Practice Address - Zip Code:32340-3091
Practice Address - Country:US
Practice Address - Phone:850-253-3732
Practice Address - Fax:850-973-6663
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL675539900171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL675539900Medicaid