Provider Demographics
NPI:1356484877
Name:JACKSON ODONDI
Entity Type:Organization
Organization Name:JACKSON ODONDI
Other - Org Name:EDEN SPRING LIVING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JACKSON
Authorized Official - Middle Name:
Authorized Official - Last Name:ODONDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-949-3585
Mailing Address - Street 1:PO BOX 15927
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-0927
Mailing Address - Country:US
Mailing Address - Phone:919-544-0874
Mailing Address - Fax:919-544-5331
Practice Address - Street 1:3812 BOOKER AVE
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-1126
Practice Address - Country:US
Practice Address - Phone:919-544-0874
Practice Address - Fax:919-544-0874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-032-073311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805238Medicaid