Healthcare Provider Details

I. General information

NPI: 1386318632
Provider Name (Legal Business Name): EDGAR HERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

178 PRIVATE ROAD 19423
SOUTH POINT OH
45680-8831
US

IV. Provider business mailing address

178 PRIVATE ROAD 19423
SOUTH POINT OH
45680-8831
US

V. Phone/Fax

Practice location:
  • Phone: 740-263-2626
  • Fax:
Mailing address:
  • Phone: 740-263-2626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2001379-TRNE
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: