=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558664250
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EDEN REHAB LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2010
-----------------------------------------------------
Last Update Date | 12/19/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6100 OLD BRANDON RD
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39042-2543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-933-1100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 119 BONNE VIE DR
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39047-8789
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-573-9974
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | MR. KENNETH J RICHE
-----------------------------------------------------
Credential | PTA
-----------------------------------------------------
Telephone | 601-573-9974
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | TA1991
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | TA2342
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | PTA2698
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | PTA2491
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------