Healthcare Provider Details

I. General information

NPI: 1225334683
Provider Name (Legal Business Name): CORYDON G EDGECOMB OD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2011
Last Update Date: 03/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1287 BROADWAY
PLACERVILLE CA
95667-5820
US

IV. Provider business mailing address

1287 BROADWAY
PLACERVILLE CA
95667-5820
US

V. Phone/Fax

Practice location:
  • Phone: 530-622-7660
  • Fax: 530-622-3753
Mailing address:
  • Phone: 530-622-7660
  • Fax: 530-622-3753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT 4245 TPA
License Number StateCA

VIII. Authorized Official

Name: DR. CORYDON EDGECOMB
Title or Position: DOCTOR
Credential: O.D.
Phone: 530-622-7660