Basic Information
| Provider Information | |||||||||
| NPI: | 1649683582 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EDEN HOME HEALTH OF IDAHO FALLS, 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: | 986626729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608926628 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2540 CHANNING WAY | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834047515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085231980 | ||||||||
| FaxNumber: | 2085234024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2014 | ||||||||
| LastUpdateDate: | 02/10/2022 | ||||||||
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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: | 02/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251J00000X | N | Agencies | Nursing Care | 374U00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Nursing Service Related Providers | Home Health Aide | 104100000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 225100000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 251E00000X | HH-248 | ID | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 1649683582 | 05 | ID | MEDICAID | 1649683582 | 01 | ID | NPI | OTHER | HH-248 | 01 | ID | STATE HOME HEALTH LICENSE | OTHER |