Provider Demographics
NPI:1902929458
Name:EDMONSOND, CHRISTOPHER (MPT)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:EDMONSOND
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1772
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-7772
Mailing Address - Country:US
Mailing Address - Phone:850-682-7772
Mailing Address - Fax:850-682-1539
Practice Address - Street 1:1950 BLUEWATER BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-3887
Practice Address - Country:US
Practice Address - Phone:850-897-3334
Practice Address - Fax:850-897-7855
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT23309225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY906WOtherBCBSFL GRP #
FLBQ086ZOtherMEDICARE PTAN
FL892071100Medicaid