Healthcare Provider Details

I. General information

NPI: 1407926561
Provider Name (Legal Business Name): EDEN PARK HEALTH SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 PARKWAY DR
COBLESKILL NY
12043-5150
US

IV. Provider business mailing address

22 HOLLAND AVE
ALBANY NY
12209-1713
US

V. Phone/Fax

Practice location:
  • Phone: 518-234-3557
  • Fax:
Mailing address:
  • Phone: 518-436-4731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number4720301N
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00312318
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name: ROBERT GLOCK
Title or Position: PRESIDENT
Credential:
Phone: 518-436-4731