Healthcare Provider Details

I. General information

NPI: 1164710711
Provider Name (Legal Business Name): EDEN'S HOME OF CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2011
Last Update Date: 07/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3716 NEWHALEM ST SW
ATLANTA GA
30331-2243
US

IV. Provider business mailing address

3904 N DRUID HILLS RD SUITE 342
DECATUR GA
30033-3105
US

V. Phone/Fax

Practice location:
  • Phone: 404-288-2333
  • Fax: 404-521-4967
Mailing address:
  • Phone: 404-288-2333
  • Fax: 404-521-4967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberPCH005676
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberPCH005676
License Number StateGA

VIII. Authorized Official

Name: DR. J BRITNEY WILLIAMS
Title or Position: CEO
Credential: DO
Phone: 404-288-2333