Provider Demographics
NPI:1396810032
Name:EDWARDS, JAMES R (DC DABCO LAC)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:R
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:DC DABCO LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2129 16TH ST
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:IN
Mailing Address - Zip Code:47421-3003
Mailing Address - Country:US
Mailing Address - Phone:812-275-3323
Mailing Address - Fax:812-277-9354
Practice Address - Street 1:2129 16TH ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421-3003
Practice Address - Country:US
Practice Address - Phone:812-275-3323
Practice Address - Fax:812-277-9354
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08000871A111NX0800X
IN871111N00000X
IN81000034A171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NX0800XChiropractic ProvidersChiropractorOrthopedic
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN00000085334OtherANTHEM BLUE CROSS BLUE SH
IN100166180Medicaid
IN014356OtherSIHO
IN100166180Medicaid