Provider Demographics
NPI:1427006386
Name:EDEN HERITAGE FOUNDATION
Entity Type:Organization
Organization Name:EDEN HERITAGE FOUNDATION
Other - Org Name:AUTUMN MEADOWS, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RAYANNE
Authorized Official - Middle Name:CARROLL
Authorized Official - Last Name:STRUBBERG
Authorized Official - Suffix:
Authorized Official - Credentials:BS/BA, LNHA
Authorized Official - Phone:573-897-2218
Mailing Address - Street 1:196 HIGHWAY CC
Mailing Address - Street 2:
Mailing Address - City:LINN
Mailing Address - State:MO
Mailing Address - Zip Code:65051-3500
Mailing Address - Country:US
Mailing Address - Phone:573-897-2218
Mailing Address - Fax:573-897-0127
Practice Address - Street 1:196 HIGHWAY CC
Practice Address - Street 2:
Practice Address - City:LINN
Practice Address - State:MO
Practice Address - Zip Code:65051-3500
Practice Address - Country:US
Practice Address - Phone:573-897-2218
Practice Address - Fax:573-897-0127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO031890314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO26-5364Medicare ID - Type UnspecifiedMEDICARE PROVIDER