Healthcare Provider Details

I. General information

NPI: 1104737634
Provider Name (Legal Business Name): MR. ELIJAH EDWARDS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1367 E LAFAYETTE ST
TALLAHASSEE FL
32301-4774
US

IV. Provider business mailing address

1367 E LAFAYETTE ST STE C
TALLAHASSEE FL
32301-4769
US

V. Phone/Fax

Practice location:
  • Phone: 229-206-4901
  • Fax:
Mailing address:
  • Phone: 229-206-4901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: