Provider Demographics
NPI:1447578117
Name:EDEN HOLISTIC MEDICINE AND WELLNESS, PC
Entity Type:Organization
Organization Name:EDEN HOLISTIC MEDICINE AND WELLNESS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLEY
Authorized Official - Middle Name:E
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:610-833-8739
Mailing Address - Street 1:412 E KING ST
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-3004
Mailing Address - Country:US
Mailing Address - Phone:610-833-8739
Mailing Address - Fax:610-647-8921
Practice Address - Street 1:412 E KING ST
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:PA
Practice Address - Zip Code:19355-3004
Practice Address - Country:US
Practice Address - Phone:610-833-8739
Practice Address - Fax:610-647-8921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-05
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS014960208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty