MEDICARE: EDE CA AT SANTA MONICA, LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1033262811
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDE CA AT SANTA MONICA, LP

Provider Business Mailing Address
First Line	:	2300 WINDY RIDGE PARKWAY
Second Line	:	SUITE 210S
City	:	ATLANTA
State	:	GA
Zip	:	30339
Country	:	US
Telephone Number	:	470-440-1647
Fax Number	:	310-829-9055

Provider Business Practice Location Address
First Line	:	2716 OCEAN PARK BLVD STE 3020
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90405-5225
Country	:	US
Telephone Number	:	310-829-9161
Fax Number	:	310-829-9055

Authorized Official
Title or Position	:	DIRECTOR OF RCM
Name	:	TYEAST REYNOLDS
Credential	:
Telephone Number	:	678-813-0428

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	04/11/2019

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