Provider Demographics
NPI:1689123440
Name:EDENS POINTE HOME CARE INC
Entity Type:Organization
Organization Name:EDENS POINTE HOME CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAMYIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEFLORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-316-3750
Mailing Address - Street 1:1839 N DR MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-3673
Mailing Address - Country:US
Mailing Address - Phone:414-316-3750
Mailing Address - Fax:
Practice Address - Street 1:1839 N DR MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-3673
Practice Address - Country:US
Practice Address - Phone:414-316-3750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100048198Medicaid