Basic Information
Provider Information | |||||||||
NPI: | 1134122179 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EDEN MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 748373 | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900748373 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8553981633 | ||||||||
FaxNumber: | 5108696592 | ||||||||
Practice Location | |||||||||
Address1: | 20103 LAKE CHABOT RD | ||||||||
Address2: |   | ||||||||
City: | CASTRO VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 945465305 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5105371234 | ||||||||
FaxNumber: | 5108896506 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2005 | ||||||||
LastUpdateDate: | 12/02/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HUNTER | ||||||||
AuthorizedOfficialFirstName: | BRIAN | ||||||||
AuthorizedOfficialMiddleName: | TRENT | ||||||||
AuthorizedOfficialTitleorPosition: | VP SHARED SERVICES | ||||||||
AuthorizedOfficialTelephone: | 9162978555 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 140000030 | CA | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | HSC00488G | 05 | CA |   | MEDICAID | HSP40488G | 05 | CA |   | MEDICAID | ZZR00488G | 05 | CA |   | MEDICAID |