Healthcare Provider Details

I. General information

NPI: 1508971169
Provider Name (Legal Business Name): STEPHEN BLAINE EDWARDS PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 10/01/2022
Certification Date: 10/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3525 LOMA VISTA RD STE C
VENTURA CA
93003-3165
US

IV. Provider business mailing address

5720 RALSTON ST STE 200
VENTURA CA
93003-7844
US

V. Phone/Fax

Practice location:
  • Phone: 805-652-6955
  • Fax: 805-652-6959
Mailing address:
  • Phone: 805-804-4168
  • Fax: 805-830-1177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT 22601
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: