Provider Demographics
NPI:1699189530
Name:EDWARDS, DALE ALWOOD (PTA)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:ALWOOD
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 ARROWHEAD ST
Mailing Address - Street 2:
Mailing Address - City:COLBY
Mailing Address - State:KS
Mailing Address - Zip Code:67701-3611
Mailing Address - Country:US
Mailing Address - Phone:785-443-3855
Mailing Address - Fax:
Practice Address - Street 1:208 W 2ND ST
Practice Address - Street 2:
Practice Address - City:GOODLAND
Practice Address - State:KS
Practice Address - Zip Code:67735-1660
Practice Address - Country:US
Practice Address - Phone:785-890-7517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-02107225200000X
KS14-02108225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant