Provider Demographics
NPI:1558664250
Name:EDEN REHAB LLC
Entity Type:Organization
Organization Name:EDEN REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:RICHE
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:601-573-9974
Mailing Address - Street 1:119 BONNE VIE DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-8789
Mailing Address - Country:US
Mailing Address - Phone:601-573-9974
Mailing Address - Fax:
Practice Address - Street 1:6100 OLD BRANDON RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-2543
Practice Address - Country:US
Practice Address - Phone:601-933-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-19
Last Update Date:2010-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSTA1991224Z00000X
MSTA2342224Z00000X
MSPTA2491225200000X
MSPTA2698225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty