Provider Demographics
NPI:1467977884
Name:EDEN FAMILY CARE AND MEDICAL AESTHETICS
Entity Type:Organization
Organization Name:EDEN FAMILY CARE AND MEDICAL AESTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP/CNM
Authorized Official - Phone:801-217-9230
Mailing Address - Street 1:PO BOX 687
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84310-0687
Mailing Address - Country:US
Mailing Address - Phone:801-217-9230
Mailing Address - Fax:
Practice Address - Street 1:2612 N HIGHWAY 162
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:UT
Practice Address - Zip Code:84310-9745
Practice Address - Country:US
Practice Address - Phone:801-217-9230
Practice Address - Fax:801-217-9230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-07
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9758122-4405363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty