Basic Information
| Provider Information | |||||||||
| NPI: | 1003356403 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EDEN HOME HEALTH OF KING COUNTY, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EDEN HOME HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4601 NE 77TH AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608926628 | ||||||||
| FaxNumber: | 3608825793 | ||||||||
| Practice Location | |||||||||
| Address1: | 733 7TH AVENUE | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | KIRKLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067178161 | ||||||||
| FaxNumber: | 2068991641 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2017 | ||||||||
| LastUpdateDate: | 10/01/2020 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO AND MANAGER OF EMPRES HEALTHCAR | ||||||||
| AuthorizedOfficialTelephone: | 3608926628 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EMPRES HOME HEALTH, LLC | ||||||||
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| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | WA | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 2145416 | 05 | WA | MEDICAID |