Provider Demographics
NPI:1023602588
Name:EDEN REJUVENATION CENTER FOR WELLBEING PLLC
Entity type:Organization
Organization Name:EDEN REJUVENATION CENTER FOR WELLBEING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:BIJU
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-471-7431
Mailing Address - Street 1:5605 FM 423, STE 500- 355
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75036-8960
Mailing Address - Country:US
Mailing Address - Phone:817-731-6121
Mailing Address - Fax:
Practice Address - Street 1:6913 CAMP BOWIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-7163
Practice Address - Country:US
Practice Address - Phone:267-471-7431
Practice Address - Fax:817-732-8015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-25
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1700170867OtherNPI