Provider Demographics
NPI:1932869476
Name:EDEN'S PROMISE
Entity Type:Organization
Organization Name:EDEN'S PROMISE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIVEN
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-201-2915
Mailing Address - Street 1:1149 SW ESTAUGH AVE
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-1810
Mailing Address - Country:US
Mailing Address - Phone:561-201-2915
Mailing Address - Fax:
Practice Address - Street 1:1149 SW ESTAUGH AVE
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-1810
Practice Address - Country:US
Practice Address - Phone:561-201-2915
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-25
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities