Provider Demographics
NPI:1891874996
Name:EDGE, DAVID WAYNE (LAC, OMD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:WAYNE
Last Name:EDGE
Suffix:
Gender:M
Credentials:LAC, OMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:396 RUSSELL WAY
Mailing Address - Street 2:
Mailing Address - City:GARDNERVILLE
Mailing Address - State:NV
Mailing Address - Zip Code:89460-6503
Mailing Address - Country:US
Mailing Address - Phone:775-781-3465
Mailing Address - Fax:775-783-7629
Practice Address - Street 1:1528 US HIGHWAY 395 N
Practice Address - Street 2:SUITE 230
Practice Address - City:GARDNERVILLE
Practice Address - State:NV
Practice Address - Zip Code:89410-5265
Practice Address - Country:US
Practice Address - Phone:775-783-4930
Practice Address - Fax:775-783-7629
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10063171100000X
NV1031171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist