MEDICARE: EDEN HOME HEALTH OF WILLAMETTE VALLEY, 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	251E00000X	Home Health Agency		OR

General Provider Information

NPI Number	:	1760922165
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDEN HOME HEALTH OF WILLAMETTE VALLEY, LLC

Provider Business Mailing Address
First Line	:	4601 NE 77TH AVE
Second Line	:	SUITE 300
City	:	VANCOUVER
State	:	WA
Zip	:	98662-6729
Country	:	US
Telephone Number	:	360-892-6628
Fax Number	:	360-882-5793

Provider Business Practice Location Address
First Line	:	380 Q ST
Second Line	:	SUITE 250
City	:	SPRINGFIELD
State	:	OR
Zip	:	97477-2120
Country	:	US
Telephone Number	:	360-892-6628
Fax Number	:	360-882-5793

Authorized Official
Title or Position	:	CEO AND MANAGER
Name	:	BRENT WEIL
Credential	:
Telephone Number	:	360-892-6628

Provider Enumeration Date	:	03/03/2017
Last Update Date	:	03/03/2017

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