MEDICARE: EDGEWOOD GRAND ISLAND SENIOR LIVING

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	311500000X	Alzheimer Center (Dementia Center)	28D1060632	NE

General Provider Information

NPI Number	:	1285923631
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDGEWOOD GRAND ISLAND SENIOR LIVING

Provider Business Mailing Address
First Line	:	214 N. PIPER
Second Line	:
City	:	GRAND ISLAND
State	:	NE
Zip	:	68803-4027
Country	:	US
Telephone Number	:	308-384-0717
Fax Number	:	308-384-0728

Provider Business Practice Location Address
First Line	:	214 N. PIPER
Second Line	:
City	:	GRAND ISLAND
State	:	NE
Zip	:	68803-4027
Country	:	US
Telephone Number	:	308-384-0717
Fax Number	:	308-384-0728

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	MR. REX CARLSON
Credential	:	CPA
Telephone Number	:	701-738-2000

Provider Enumeration Date	:	04/06/2011
Last Update Date	:	04/06/2011

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Directions to “EDGEWOOD GRAND ISLAND SENIOR LIVING ” Practice Location

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