Basic Information
| Provider Information | |||||||||
| NPI: | 1194369892 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | THEO | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 207 N. HWY 59, KANSAS OK | ||||||||
| Address2: | |||||||||
| City: | KANSAS | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743470000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187864434 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 211 N HIGHWAY 59 | ||||||||
| Address2: | |||||||||
| City: | KANSAS | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743477076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187864434 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2019 | ||||||||
| LastUpdateDate: | 12/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/19/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.