Healthcare Provider Details

I. General information

NPI: 1033561956
Provider Name (Legal Business Name): EDENS HEALTH GROUP LAWRENCEVILLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2016
Last Update Date: 07/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2011 COMMERCE DR N SUITE 25
PEACHTREE CITY GA
30269-3538
US

IV. Provider business mailing address

PO BOX 629
PERRY GA
31069-0629
US

V. Phone/Fax

Practice location:
  • Phone: 770-317-7773
  • Fax: 855-491-8879
Mailing address:
  • Phone: 855-691-8869
  • Fax: 855-691-8879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER ALTON EDENS
Title or Position: PRESIDENT
Credential: MD
Phone: 855-491-8869