Provider Demographics
NPI:1912468711
Name:EDEN HOUSE HOME CARE, LLC
Entity type:Organization
Organization Name:EDEN HOUSE HOME CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:870-394-4818
Mailing Address - Street 1:120 W TYLER AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-4221
Mailing Address - Country:US
Mailing Address - Phone:870-394-4818
Mailing Address - Fax:870-394-4806
Practice Address - Street 1:120 W TYLER AVE STE 200
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4221
Practice Address - Country:US
Practice Address - Phone:870-394-4818
Practice Address - Fax:870-394-4806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-26
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR224879732Medicaid