Healthcare Provider Details

I. General information

NPI: 1568955037
Provider Name (Legal Business Name): EDGEWATER SYSTEMS FOR BALANCED LIVING, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2018
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 W 5TH AVE
GARY IN
46402-1723
US

IV. Provider business mailing address

1100 W 6TH AVE
GARY IN
46402-1711
US

V. Phone/Fax

Practice location:
  • Phone: 219-885-4264
  • Fax:
Mailing address:
  • Phone: 219-885-4264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: SHIRLEY A ROLL
Title or Position: ENROLLMENT
Credential:
Phone: 317-472-7396