=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811741796
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW EDEN HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2024
-----------------------------------------------------
Last Update Date | 04/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3011 MARSHFIELD PRESERVE WAY
-----------------------------------------------------
City | KISSIMMEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34746-2105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-519-7951
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7385 NW 68TH WAY
-----------------------------------------------------
City | PARKLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33067-3918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-519-7951
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GARDINE JACQUES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-519-7951
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------