Provider Demographics
NPI:1881166981
Name:ALPHA KIDS SHINE
Entity type:Organization
Organization Name:ALPHA KIDS SHINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:EDMONDS
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:773-828-9106
Mailing Address - Street 1:525 S CHURCH ST APT 1911
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-3321
Mailing Address - Country:US
Mailing Address - Phone:773-828-9106
Mailing Address - Fax:
Practice Address - Street 1:8612 S PAULINA ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60620-4849
Practice Address - Country:US
Practice Address - Phone:773-828-9106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-30
Last Update Date:2018-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty