Healthcare Provider Details

I. General information

NPI: 1760503221
Provider Name (Legal Business Name): EDGE PHYSICAL THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1695 S SAN JACINTO ST STE C
SAN JACINTO CA
92583
US

IV. Provider business mailing address

14 DOLORES CT
REDLANDS CA
92374-5567
US

V. Phone/Fax

Practice location:
  • Phone: 951-665-1510
  • Fax: 951-665-1515
Mailing address:
  • Phone: 951-665-1510
  • Fax: 951-665-1515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID EVAN SHUEY
Title or Position: PHYSICAL THERAPIST ASSISTANT
Credential: PTA
Phone: 909-831-6867