Provider Demographics
NPI:1942862552
Name:EDH1 LLC
Entity Type:Organization
Organization Name:EDH1 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ELSTON
Authorized Official - Middle Name:DERREK
Authorized Official - Last Name:HOOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:980-297-0703
Mailing Address - Street 1:9027 TIBBLE CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227-6670
Mailing Address - Country:US
Mailing Address - Phone:980-297-0703
Mailing Address - Fax:
Practice Address - Street 1:9027 TIBBLE CREEK WAY
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227-6670
Practice Address - Country:US
Practice Address - Phone:980-297-0703
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-03
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Single Specialty
No302F00000XManaged Care OrganizationsExclusive Provider OrganizationGroup - Single Specialty