Provider Demographics
NPI:1215579537
Name:EDEN PRAIRIE RESIDENTIAL CARE SERVICES, LLC
Entity Type:Organization
Organization Name:EDEN PRAIRIE RESIDENTIAL CARE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEHINDE
Authorized Official - Middle Name:OLUGBOLAHAN
Authorized Official - Last Name:OGUNDIPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-250-6576
Mailing Address - Street 1:302 WELCH BLVD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-1105
Mailing Address - Country:US
Mailing Address - Phone:214-250-6576
Mailing Address - Fax:810-337-1546
Practice Address - Street 1:302 WELCH BLVD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-1105
Practice Address - Country:US
Practice Address - Phone:214-250-6576
Practice Address - Fax:810-337-1546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities