Basic Information
| Provider Information | |||||||||
| NPI: | 1538778295 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EDEN HOME HEALTH OF CLARK COUNTY, LLC | ||||||||
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| OtherOrganizationName: | EDEN HOME HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4601 NE 77TH AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986626736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608926628 | ||||||||
| FaxNumber: | 3608825793 | ||||||||
| Practice Location | |||||||||
| Address1: | 2621 NE 134TH ST STE 140 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986863036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605040122 | ||||||||
| FaxNumber: | 3608591354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2020 | ||||||||
| LastUpdateDate: | 05/27/2022 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO AND ASSISTANT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3608926628 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EMPRES HOME HEALTH, LLC | ||||||||
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| NPICertificationDate: | 05/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | IHS.FS.61097918 | 01 | WA | STATE LICENSE | OTHER | 50-7133 | 01 | WA | PTAN | OTHER | 1538778295 | 01 | WA | NPI | OTHER | 16-1096 | 01 | OR | STATE LICENSE | OTHER |