Provider Demographics
NPI:1992228738
Name:INA, EDMOND CHRISTOPHER (LAT, ATC)
Entity type:Individual
Prefix:
First Name:EDMOND
Middle Name:CHRISTOPHER
Last Name:INA
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 MOONEY ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1901 MOONEY ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3032
Practice Address - Country:US
Practice Address - Phone:336-713-5230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-24
Last Update Date:2017-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer