Provider Demographics
NPI:1205280120
Name:EDEN MANOR LLC
Entity type:Organization
Organization Name:EDEN MANOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-814-2594
Mailing Address - Street 1:1361 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-4131
Mailing Address - Country:US
Mailing Address - Phone:314-833-4313
Mailing Address - Fax:314-833-4313
Practice Address - Street 1:1361 ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-4131
Practice Address - Country:US
Practice Address - Phone:314-833-4313
Practice Address - Fax:314-833-4313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-17
Last Update Date:2016-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOLC9786208251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health