Provider Demographics
NPI:1831941996
Name:MEDINA, EDGAR C
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:C
Last Name:MEDINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 KENDALL TOWN BLVD UNIT 6313
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-7295
Mailing Address - Country:US
Mailing Address - Phone:305-219-7703
Mailing Address - Fax:
Practice Address - Street 1:1290 KENDALL TOWN BLVD UNIT 6313
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-7295
Practice Address - Country:US
Practice Address - Phone:305-219-7703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA97468225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist