Provider Demographics
NPI:1932611811
Name:CANADA, EDGAR
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:CANADA
Suffix:
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 1:409 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257-2336
Mailing Address - Country:US
Mailing Address - Phone:559-784-0312
Mailing Address - Fax:
Practice Address - Street 1:409 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-2336
Practice Address - Country:US
Practice Address - Phone:559-784-0312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator