Healthcare Provider Details

I. General information

NPI: 1558065417
Provider Name (Legal Business Name): CHRISTIANIA VIOLA EDSTROM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 N FLAMINGO RD
PEMBROKE PINES FL
33028-1006
US

IV. Provider business mailing address

145 HIBISCUS PL
RIVER RIDGE LA
70123-2505
US

V. Phone/Fax

Practice location:
  • Phone: 954-518-5936
  • Fax:
Mailing address:
  • Phone: 612-859-9858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberME181303
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: