=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073133997
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EDEN PARADISE ASSISTED LIVING,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2020
-----------------------------------------------------
Last Update Date | 04/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6 NW 35TH AVE
-----------------------------------------------------
City | CAPE CORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33993-6932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-282-2556
-----------------------------------------------------
Fax | 239-282-1558
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 NW 35TH AVE
-----------------------------------------------------
City | CAPE CORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33993-6932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-282-2556
-----------------------------------------------------
Fax | 239-282-1558
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | JEANNE TAMAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 239-645-5003
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------