Provider Demographics
NPI:1912584616
Name:BACK TO EDEN COMMUNITY CLINIC LLC
Entity Type:Organization
Organization Name:BACK TO EDEN COMMUNITY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TUNYESSE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MURPHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-224-7163
Mailing Address - Street 1:720 DAVINCI CT
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-2205
Mailing Address - Country:US
Mailing Address - Phone:708-224-7163
Mailing Address - Fax:
Practice Address - Street 1:720 DAVINCI CT
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-2205
Practice Address - Country:US
Practice Address - Phone:708-224-7163
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BACK TO EDEN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-03-27
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory