Provider Demographics
NPI:1487065652
Name:RED NEST, EDISON MICHAEL III
Entity type:Individual
Prefix:MR
First Name:EDISON
Middle Name:MICHAEL
Last Name:RED NEST
Suffix:III
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 1:217 BOX BUTTE AVENUE
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:NE
Mailing Address - Zip Code:69301
Mailing Address - Country:US
Mailing Address - Phone:308-458-7795
Mailing Address - Fax:
Practice Address - Street 1:217 BOX BUTTE AVE
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:NE
Practice Address - Zip Code:69301-3741
Practice Address - Country:US
Practice Address - Phone:308-458-7795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-09
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker