Provider Demographics
NPI:1093885840
Name:EDEN PARK MANAGEMENT, INC.
Entity Type:Organization
Organization Name:EDEN PARK MANAGEMENT, INC.
Other - Org Name:EDEN PARK OF BRATTLEBORO
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALTON
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDLESON, JR.
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-436-4731
Mailing Address - Street 1:22 HOLLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12209-1713
Mailing Address - Country:US
Mailing Address - Phone:518-436-4731
Mailing Address - Fax:
Practice Address - Street 1:187 OAK GROVE AVE
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-6642
Practice Address - Country:US
Practice Address - Phone:802-257-0307
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0475023Medicaid
VT0475023Medicaid