Healthcare Provider Details

I. General information

NPI: 1023489218
Provider Name (Legal Business Name): DENEB EDWARDS M.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2015
Last Update Date: 10/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 OAKLEY AVE
BURLEY ID
83318-1833
US

IV. Provider business mailing address

621 DOGGETT DR
HEYBURN ID
83336-9639
US

V. Phone/Fax

Practice location:
  • Phone: 208-244-2585
  • Fax:
Mailing address:
  • Phone: 208-244-2585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMASG-1932
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: