MEDICARE: EDEN HEALTHCARE SERVICES, LLC

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	251B00000X	Case Management Agency		LA
2	251S00000X	Community/Behavioral Health Agency		LA

General Provider Information

NPI Number	:	1568788792
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDEN HEALTHCARE SERVICES, LLC

Provider Business Mailing Address
First Line	:	1010 COMMON ST
Second Line	:	2410
City	:	NEW ORLEANS
State	:	LA
Zip	:	70112-2401
Country	:	US
Telephone Number	:	504-523-9444
Fax Number	:	504-523-9445

Provider Business Practice Location Address
First Line	:	1010 COMMON ST
Second Line	:	2410
City	:	NEW ORLEANS
State	:	LA
Zip	:	70112-2401
Country	:	US
Telephone Number	:	504-523-9444
Fax Number	:	504-523-9445

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	MR. DWAYNE D GRAY
Credential	:
Telephone Number	:	504-523-9444

Provider Enumeration Date	:	04/13/2010
Last Update Date	:	04/13/2010

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