Healthcare Provider Details

I. General information

NPI: 1780276162
Provider Name (Legal Business Name): EDENS PLACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2021
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4111 AVENUE L
BIRMINGHAM AL
35208-1807
US

IV. Provider business mailing address

4111 AVENUE L
BIRMINGHAM AL
35208-1807
US

V. Phone/Fax

Practice location:
  • Phone: 803-849-2925
  • Fax:
Mailing address:
  • Phone: 803-849-2925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: EDNECIA FITZPATRICK
Title or Position: OWNER
Credential:
Phone: 803-849-2925