Basic Information
| Provider Information | |||||||||
| NPI: | 1760503221 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EDGE PHYSICAL THERAPY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14 DOLORES CT | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923745567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516651510 | ||||||||
| FaxNumber: | 9516651515 | ||||||||
| Practice Location | |||||||||
| Address1: | 1695 S SAN JACINTO ST | ||||||||
| Address2: | STE C | ||||||||
| City: | SAN JACINTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516651510 | ||||||||
| FaxNumber: | 9516651515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 06/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | SHUEY | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | EVAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 9098316867 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PTA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.