Provider Demographics
NPI:1366156614
Name:EDWARDS, DERRICK DWAYNE
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:DWAYNE
Last Name:EDWARDS
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 1:2321 COOLMIST CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ELM
Mailing Address - State:TX
Mailing Address - Zip Code:75068-0197
Mailing Address - Country:US
Mailing Address - Phone:469-481-6874
Mailing Address - Fax:
Practice Address - Street 1:2321 COOLMIST CREEK DR
Practice Address - Street 2:
Practice Address - City:LITTLE ELM
Practice Address - State:TX
Practice Address - Zip Code:75068-0197
Practice Address - Country:US
Practice Address - Phone:469-481-6874
Practice Address - Fax:214-618-0724
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility