Provider Demographics
NPI:1376099929
Name:EDEN DIAGNOSTIC ASSOCIATES
Entity Type:Organization
Organization Name:EDEN DIAGNOSTIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:ANGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-508-7008
Mailing Address - Street 1:5906 E 31ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-5110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5906 E 31ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-5110
Practice Address - Country:US
Practice Address - Phone:918-508-7008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1709174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty