Provider Demographics
NPI:1083132518
Name:EDEN MEDICAL TRANSPORTATION
Entity Type:Organization
Organization Name:EDEN MEDICAL TRANSPORTATION
Other - Org Name:EDEN MEDICA TRANSPORTATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:AWWAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:ISMAIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-957-8383
Mailing Address - Street 1:PO BOX 3851
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-0851
Mailing Address - Country:US
Mailing Address - Phone:510-957-8383
Mailing Address - Fax:510-263-5754
Practice Address - Street 1:1601 165TH AVE APT 107
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-3164
Practice Address - Country:US
Practice Address - Phone:510-957-8383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA127968343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)