MEDICARE: EDGEWATER SYSTEMS FOR BALANCED LIVING, 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	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1245907344
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDGEWATER SYSTEMS FOR BALANCED LIVING, INC

Provider Business Mailing Address
First Line	:	1100 W 6TH AVE
Second Line	:
City	:	GARY
State	:	IN
Zip	:	46402-1711
Country	:	US
Telephone Number	:	219-885-4264
Fax Number	:

Provider Business Practice Location Address
First Line	:	426 S LAKE ST
Second Line	:
City	:	GARY
State	:	IN
Zip	:	46403-2405
Country	:	US
Telephone Number	:	219-939-6070
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DANITA JOHNSON HUGHES
Credential	:
Telephone Number	:	219-885-4264

Provider Enumeration Date	:	08/26/2021
Last Update Date	:	08/26/2021

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