1467977884 NPI number — EDEN FAMILY CARE AND MEDICAL AESTHETICS

Table of content: (NPI 1467977884)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467977884 NPI number — EDEN FAMILY CARE AND MEDICAL AESTHETICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDEN FAMILY CARE AND MEDICAL AESTHETICS
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:
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:
1467977884
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 687
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDEN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84310-0687
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-217-9230
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2612 N HIGHWAY 162
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDEN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84310-9745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-217-9230
Provider Business Practice Location Address Fax Number:
801-217-9230
Provider Enumeration Date:
08/07/2017

Additional Information

Authorized Official

Authorized Official Last Name:
GARDNER
Authorized Official First Name:
MARY
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
NURSE PRACTITIONER/OWNER
Authorized Official Telephone Number:
801-217-9230

Provider Taxonomy Codes

  • Taxonomy code: 363LP2300X , with the licence number:  9758122-4405 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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