Provider Demographics
NPI:1598381212
Name:EDEN MEDICAL SUPPLY, LLC
Entity Type:Organization
Organization Name:EDEN MEDICAL SUPPLY, LLC
Other - Org Name:EDEN MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF BUSINESS DEVELOPMENT/CE
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MASCIARELLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-838-3560
Mailing Address - Street 1:7300 N FEDERAL HWY STE 102
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-1631
Mailing Address - Country:US
Mailing Address - Phone:800-838-3560
Mailing Address - Fax:866-589-3366
Practice Address - Street 1:7300 N FEDERAL HWY STE 102
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-1631
Practice Address - Country:US
Practice Address - Phone:800-838-3560
Practice Address - Fax:866-589-3366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-18
Last Update Date:2024-04-01
Deactivation Date:2021-06-02
Deactivation Code:
Reactivation Date:2021-07-12
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
HUMANAOtherHUMANA