Healthcare Provider Details

I. General information

NPI: 1770129793
Provider Name (Legal Business Name): EDGEWOOD MAXIMUS OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2019
Last Update Date: 11/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1771 EDGEWOOD AVE W
JACKSONVILLE FL
32208-3278
US

IV. Provider business mailing address

PO BOX 9268
HICKORY NC
28603-9268
US

V. Phone/Fax

Practice location:
  • Phone: 904-766-7436
  • Fax:
Mailing address:
  • Phone: 828-322-8171
  • Fax: 828-322-3704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: LYNNE PLACE
Title or Position: VP OF FINANCE
Credential:
Phone: 828-322-8171