Provider Demographics
NPI:1902830284
Name:EDEN SPORTS, INC.
Entity Type:Organization
Organization Name:EDEN SPORTS, INC.
Other - Org Name:THERASPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAYNE
Authorized Official - Middle Name:FLECK
Authorized Official - Last Name:POOL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-467-8705
Mailing Address - Street 1:665 PHILADELPHIA ST
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-3941
Mailing Address - Country:US
Mailing Address - Phone:724-465-3496
Mailing Address - Fax:724-465-3726
Practice Address - Street 1:4446 US HIGHWAY 220 N STE A
Practice Address - Street 2:SUMMERFIELD VILLAGE
Practice Address - City:SUMMERFIELD
Practice Address - State:NC
Practice Address - Zip Code:27358-9415
Practice Address - Country:US
Practice Address - Phone:336-643-7335
Practice Address - Fax:336-643-7365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC346576Medicare Oscar/Certification