Provider Demographics
NPI:1104447267
Name:ACTIVE SENIORS CONSULTING DBA THE EDEN INN
Entity type:Organization
Organization Name:ACTIVE SENIORS CONSULTING DBA THE EDEN INN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-347-7495
Mailing Address - Street 1:4064 SW 51ST ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-5712
Mailing Address - Country:US
Mailing Address - Phone:954-581-2240
Mailing Address - Fax:954-581-2240
Practice Address - Street 1:4064 SW 51ST ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33314-5712
Practice Address - Country:US
Practice Address - Phone:954-581-2240
Practice Address - Fax:954-581-2240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-29
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9545812240Medicaid
FLNONEOtherASSISTANCE LIVING