Healthcare Provider Details

I. General information

NPI: 1376219147
Provider Name (Legal Business Name): EDEN PRACTITIONERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2021
Last Update Date: 08/12/2022
Certification Date: 08/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

843 E MAIN ST STE 204
MEDFORD OR
97504-7137
US

IV. Provider business mailing address

843 E MAIN ST STE 204
MEDFORD OR
97504-7137
US

V. Phone/Fax

Practice location:
  • Phone: 541-329-0478
  • Fax: 541-314-9556
Mailing address:
  • Phone: 541-329-0478
  • Fax: 541-314-9556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. DANE FICKES
Title or Position: OWNER
Credential:
Phone: 541-329-0478