=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538517727
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWIN CLAUDE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2016
-----------------------------------------------------
Last Update Date | 05/27/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1150 CONNETQUOT AVE
-----------------------------------------------------
City | CENTRAL ISLIP
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11722-3427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-810-0079
-----------------------------------------------------
Fax | 631-630-0083
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | POBOX 756 1150 CONNETQUOT AVE
-----------------------------------------------------
City | CENTRAL ISLIP
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-810-0079
-----------------------------------------------------
Fax | 631-630-0083
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 34985-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------