1346898830 NPI number — EDEN HOME HEALTH OF SANDPOINT, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346898830 NPI number — EDEN HOME HEALTH OF SANDPOINT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDEN HOME HEALTH OF SANDPOINT, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346898830
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4601 NE 77TH AVE STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98662-6736
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-892-6628
Provider Business Mailing Address Fax Number:
360-882-5793

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
204 TRIANGLE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PONDERAY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83852-9729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-255-1640
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/28/2019

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
CEO AND ASSISTANT MANAGER
Authorized Official Telephone Number:
360-892-6628

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 13-7122 . This is a "PTAN" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 1346898830 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: HH-247 . This is a "HOME HEALTH AGENCY LICENSE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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