MEDICARE: EDEN STAR LIVING LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility
2	385HR2060X	Child Intellectual and/or Developmental Disabilities Respite Care
3	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1245738707
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDEN STAR LIVING LLC

Provider Business Mailing Address
First Line	:	13250 WESTHEIMER RD APT 202
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77077-3586
Country	:	US
Telephone Number	:	720-365-4942
Fax Number	:

Provider Business Practice Location Address
First Line	:	13250 WESTHEIMER RD APT 202
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77077-3586
Country	:	US
Telephone Number	:	720-365-4942
Fax Number	:

Authorized Official
Title or Position	:	C.E.O.
Name	:	ADENIKE KOTUN
Credential	:
Telephone Number	:	720-365-4942

Provider Enumeration Date	:	01/30/2018
Last Update Date	:	01/30/2018

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Directions to “EDEN STAR LIVING LLC ” Practice Location

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