Provider Demographics
NPI:1144471327
Name:VAN EEDEN, LLC
Entity type:Organization
Organization Name:VAN EEDEN, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JOHNETTE
Authorized Official - Middle Name:H
Authorized Official - Last Name:VAN EEDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-571-6425
Mailing Address - Street 1:451 WESTPARK WAY STE 1
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76040-3994
Mailing Address - Country:US
Mailing Address - Phone:817-571-6425
Mailing Address - Fax:
Practice Address - Street 1:451 WESTPARK WAY STE 1
Practice Address - Street 2:
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76040-3994
Practice Address - Country:US
Practice Address - Phone:817-571-6425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-06
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD97387Medicare UPIN