Healthcare Provider Details

I. General information

NPI: 1508790833
Provider Name (Legal Business Name): EDGEWOOD CASA GRANDE AZ02 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 N PEART RD
CASA GRANDE AZ
85122-2564
US

IV. Provider business mailing address

PO BOX 13238
GRAND FORKS ND
58208-3238
US

V. Phone/Fax

Practice location:
  • Phone: 520-280-0339
  • Fax:
Mailing address:
  • Phone: 701-738-2000
  • Fax: 701-738-2000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: JOHN DYBWAD
Title or Position: VP FINANCE/BUDGET
Credential:
Phone: 701-738-2000