Healthcare Provider Details

I. General information

NPI: 1427018449
Provider Name (Legal Business Name): EDWIN L HARLESS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 KIMEL PARK RD VA OUTPATIENT CLINIC
WINSTON-SALEM NC
27103
US

IV. Provider business mailing address

3531 STANCLIFF RD
CLEMMONS NC
27012-8522
US

V. Phone/Fax

Practice location:
  • Phone: 336-768-3296
  • Fax: 336-760-5496
Mailing address:
  • Phone: 336-766-0778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number1428
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: