Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | IL | |
N | 111NR0400X | Rehabilitation Chiropractor | IL |
NPI | 1407026826 |
---|---|
Provider Name | Dr. Johnathan William Edwards |
First Address | Rockford, IL 61114-4807 |
Second Address | Rockford, IL 61114-4807 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/03/2008 |
Last Update Date | 03/03/2008 |