Provider Demographics
NPI:1487430971
Name:EDEN WELLNESS CENTER CORPORATION LLC
Entity type:Organization
Organization Name:EDEN WELLNESS CENTER CORPORATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:NTARE
Authorized Official - Middle Name:SERGE
Authorized Official - Last Name:SANDRALI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-938-6189
Mailing Address - Street 1:6975 SW SANDBURG ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8073
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6975 SW SANDBURG ST
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8073
Practice Address - Country:US
Practice Address - Phone:480-938-6189
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health