Provider Demographics
NPI:1790085561
Name:BACK TO EDEN
Entity Type:Organization
Organization Name:BACK TO EDEN
Other - Org Name:BACK TO EDEN WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYNNETTE
Authorized Official - Middle Name:R
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:CNHP,ND
Authorized Official - Phone:772-600-5815
Mailing Address - Street 1:209 SW FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-1005
Mailing Address - Country:US
Mailing Address - Phone:772-600-5815
Mailing Address - Fax:772-600-8012
Practice Address - Street 1:209 SW FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2003
Practice Address - Country:US
Practice Address - Phone:772-600-5815
Practice Address - Fax:772-600-8012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175F00000X
FLMM27262225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty