Provider Demographics
NPI:1790855864
Name:EDEN PARK HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:EDEN PARK HEALTH SERVICES, INC.
Other - Org Name:EDEN PARK HEALTH CARE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-436-4731
Mailing Address - Street 1:22 HOLLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12209-1713
Mailing Address - Country:US
Mailing Address - Phone:518-436-4731
Mailing Address - Fax:
Practice Address - Street 1:154 JEFFERSON HTS
Practice Address - Street 2:
Practice Address - City:CATSKILL
Practice Address - State:NY
Practice Address - Zip Code:12414-1215
Practice Address - Country:US
Practice Address - Phone:518-943-5151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1921301N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00312285Medicaid
NY00312285Medicaid