Provider Demographics
NPI:1073345708
Name:EDEN TOTAL CARE
Entity type:Organization
Organization Name:EDEN TOTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:DENEICE
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, PMHNP-BC
Authorized Official - Phone:832-833-4125
Mailing Address - Street 1:6250 JASPER DR
Mailing Address - Street 2:
Mailing Address - City:REMBERT
Mailing Address - State:SC
Mailing Address - Zip Code:29128-9133
Mailing Address - Country:US
Mailing Address - Phone:803-565-9758
Mailing Address - Fax:
Practice Address - Street 1:8300 BOONE BLVD STE 500
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-2681
Practice Address - Country:US
Practice Address - Phone:832-833-4125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-20
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty