Healthcare Provider Details

I. General information

NPI: 1982838702
Provider Name (Legal Business Name): EDGAR LEE NEAL IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2009
Last Update Date: 05/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8409 WEREWOLF RUN
MOODY A F B GA
31699-1806
US

IV. Provider business mailing address

8409 WEREWOLF RUN
MOODY A F B GA
31699-1806
US

V. Phone/Fax

Practice location:
  • Phone: 229-257-6130
  • Fax:
Mailing address:
  • Phone: 229-257-6130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: