MEDICARE: EDEN HOME CARE 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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1619688231
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDEN HOME CARE LLC

Provider Business Mailing Address
First Line	:	5525 N STANTON ST APT 24B
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-6407
Country	:	US
Telephone Number	:	360-360-8539
Fax Number	:

Provider Business Practice Location Address
First Line	:	5525 N STANTON ST APT 24B
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-6407
Country	:	US
Telephone Number	:	360-360-8539
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	EDUARDO BAUTISTA
Credential	:
Telephone Number	:	360-360-8539

Provider Enumeration Date	:	12/06/2022
Last Update Date	:	12/06/2022

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