Provider Demographics
NPI:1376219147
Name:EDEN PRACTITIONERS LLC
Entity Type:Organization
Organization Name:EDEN PRACTITIONERS LLC
Other - Org Name:EDEN PRACTITIONERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANE
Authorized Official - Middle Name:
Authorized Official - Last Name:FICKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-329-0478
Mailing Address - Street 1:843 E MAIN ST STE 204
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7137
Mailing Address - Country:US
Mailing Address - Phone:541-329-0478
Mailing Address - Fax:541-314-9556
Practice Address - Street 1:843 E MAIN ST STE 204
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7137
Practice Address - Country:US
Practice Address - Phone:541-329-0478
Practice Address - Fax:541-314-9556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-20
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity HealthGroup - Multi-Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity HealthGroup - Multi-Specialty