MEDICARE: DERRICK DWAYNE EDWARDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1366156614
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DERRICK DWAYNE EDWARDS

Provider Business Mailing Address
First Line	:	2321 COOLMIST CREEK DR
Second Line	:
City	:	LITTLE ELM
State	:	TX
Zip	:	75068-0197
Country	:	US
Telephone Number	:	469-481-6874
Fax Number	:

Provider Business Practice Location Address
First Line	:	2321 COOLMIST CREEK DR
Second Line	:
City	:	LITTLE ELM
State	:	TX
Zip	:	75068-0197
Country	:	US
Telephone Number	:	469-481-6874
Fax Number	:	214-618-0724

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2023
Last Update Date	:	01/11/2023

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