Healthcare Provider Details

I. General information

NPI: 1114931292
Provider Name (Legal Business Name): EDWARD ANTHONY JENDRISAK PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4054 FORESTRIDGE DR
RICHFIELD OH
44286-9576
US

IV. Provider business mailing address

4054 FORESTRIDGE DR
RICHFIELD OH
44286-9576
US

V. Phone/Fax

Practice location:
  • Phone: 330-659-0769
  • Fax:
Mailing address:
  • Phone: 330-659-0769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License NumberPT05915
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: