Healthcare Provider Details

I. General information

NPI: 1558382986
Provider Name (Legal Business Name): CORYDON G EDGECOMB OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 08/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1287 BROADWAY SUITE 1
PLACERVILLE CA
95667-5805
US

IV. Provider business mailing address

1287 BROADWAY SUITE 1
PLACERVILLE CA
95667-5805
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 Number4245T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: