MEDICARE: EDEN PARK HEALTH SERVICES, INC.

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	314000000X	Skilled Nursing Facility	1921301N	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790855864
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDEN PARK HEALTH SERVICES, INC.

Provider Business Mailing Address
First Line	:	22 HOLLAND AVE
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12209-1713
Country	:	US
Telephone Number	:	518-436-4731
Fax Number	:

Provider Business Practice Location Address
First Line	:	154 JEFFERSON HTS
Second Line	:
City	:	CATSKILL
State	:	NY
Zip	:	12414-1215
Country	:	US
Telephone Number	:	518-943-5151
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ROBERT GLOCK
Credential	:
Telephone Number	:	518-436-4731

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	08/22/2020

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