Provider Demographics
NPI:1215113188
Name:EDELSON, KEN (LMT)
Entity type:Individual
Prefix:MR
First Name:KEN
Middle Name:
Last Name:EDELSON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4633 PINE GROVE DR
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33445-3822
Mailing Address - Country:US
Mailing Address - Phone:561-271-5886
Mailing Address - Fax:561-496-1972
Practice Address - Street 1:5458 TOWN CENTER RD
Practice Address - Street 2:SUITE 15
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-1089
Practice Address - Country:US
Practice Address - Phone:561-271-5886
Practice Address - Fax:561-496-1972
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA14560225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist