Provider Demographics
NPI:1891865432
Name:EDEN PARK HEALTH SERVICES, INC
Entity Type:Organization
Organization Name:EDEN PARK HEALTH SERVICES, INC
Other - Org Name:EDEN PARK HEALTH SERVICES, INC. ALP
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 1:2405 15TH ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-1702
Practice Address - Country:US
Practice Address - Phone:518-266-9654
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY600-F-246310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06066571Medicaid