Provider Demographics
NPI:1336358621
Name:EDEN TERRACE
Entity Type:Organization
Organization Name:EDEN TERRACE
Other - Org Name:EDEN GARDENS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH CARE COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:QUEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-457-9710
Mailing Address - Street 1:2517 LITTLE RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76016-1314
Mailing Address - Country:US
Mailing Address - Phone:817-457-9710
Mailing Address - Fax:817-446-3264
Practice Address - Street 1:2517 LITTLE RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76016-1314
Practice Address - Country:US
Practice Address - Phone:817-457-9710
Practice Address - Fax:817-446-3264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX119504310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX119504OtherPERMIT NUMBER