Healthcare Provider Details

I. General information

NPI: 1649879958
Provider Name (Legal Business Name): JAMES MICHAEL EDMONDSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2020
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 NEEDHAM ST
MODESTO CA
95354-0730
US

IV. Provider business mailing address

1712 CARVER RD APT 19
MODESTO CA
95350-3800
US

V. Phone/Fax

Practice location:
  • Phone: 209-569-0373
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: