1972735843 NPI number — MR. JOSEPH JACKSON EDWARDS III PTA

Table of content: MR. JOSEPH JACKSON EDWARDS III PTA (NPI 1972735843)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972735843 NPI number — MR. JOSEPH JACKSON EDWARDS III PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDWARDS
Provider First Name:
JOSEPH
Provider Middle Name:
JACKSON
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
Provider Credential Text:
PTA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972735843
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
507 STINSON DR
Provider Second Line Business Mailing Address:
UNIT G2
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29407-6221
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-810-9490
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4390 BELLE OAKS DR
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
NORTH CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29405-8559
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-571-2700
Provider Business Practice Location Address Fax Number:
877-571-2124
Provider Enumeration Date:
08/11/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225200000X , with the licence number:  2355 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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