Healthcare Provider Details

I. General information

NPI: 1639884984
Provider Name (Legal Business Name): EDWARDS PROVISION SUPPORT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2023
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 INVESTORS PLACE STE 104 PMB 1056
VIRGINIA BEACH VA
23452
US

IV. Provider business mailing address

424 INVESTORS PLACE STE 104 PMB 1056
VIRGINIA BEACH VA
23452
US

V. Phone/Fax

Practice location:
  • Phone: 757-286-4212
  • Fax: 757-866-5162
Mailing address:
  • Phone: 757-286-4212
  • Fax: 757-866-5162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE THORNTON
Title or Position: OWNER
Credential:
Phone: 757-286-4212