Provider Demographics
NPI:1346898830
Name:EDEN HOME HEALTH OF SANDPOINT, LLC
Entity Type:Organization
Organization Name:EDEN HOME HEALTH OF SANDPOINT, LLC
Other - Org Name:EDEN HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO AND ASSISTANT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-892-6628
Mailing Address - Street 1:4601 NE 77TH AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6736
Mailing Address - Country:US
Mailing Address - Phone:360-892-6628
Mailing Address - Fax:360-882-5793
Practice Address - Street 1:204 TRIANGLE DR
Practice Address - Street 2:
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-9729
Practice Address - Country:US
Practice Address - Phone:208-255-1640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EMPRES HOME HEALTH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-08-28
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome Health
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID13-7122OtherPTAN
ID1346898830Medicaid
IDHH-247OtherHOME HEALTH AGENCY LICENSE