Provider Demographics
NPI:1730388893
Name:KARK, EDEN (DOM)
Entity type:Individual
Prefix:DR
First Name:EDEN
Middle Name:
Last Name:KARK
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 IRVINE ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-2546
Mailing Address - Country:US
Mailing Address - Phone:505-660-8802
Mailing Address - Fax:
Practice Address - Street 1:234 IRVINE ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-2546
Practice Address - Country:US
Practice Address - Phone:505-660-8802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM767171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist