Basic Information
| Provider Information | |||||||||
| NPI: | 1922435833 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDNIE | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10790 RANCHO BERNARDO RD | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921275705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7606336507 | ||||||||
| FaxNumber: | 7606337348 | ||||||||
| Practice Location | |||||||||
| Address1: | 71 GENTRY DR | ||||||||
| Address2: | |||||||||
| City: | FAIR HAVEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077043439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9086012862 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2013 | ||||||||
| LastUpdateDate: | 01/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01369500 | NJ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 298918 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 036902-1 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.