Healthcare Provider Details

I. General information

NPI: 1518248640
Provider Name (Legal Business Name): EDWIN CHARLES BROADNAX
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2011
Last Update Date: 09/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 UNIVERSITY AVENUE, SUITE 400
RIVERSIDE CA
92501
US

IV. Provider business mailing address

3801 UNIVERSITY AVENUE, SUITE 400
RIVERSIDE CA
92501
US

V. Phone/Fax

Practice location:
  • Phone: 951-955-7108
  • Fax:
Mailing address:
  • Phone: 951-955-7108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number104100000X
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: