Healthcare Provider Details

I. General information

NPI: 1770960536
Provider Name (Legal Business Name): EDGEWATER SYSTEMS FOR BALANCED LIVING, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2015
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4747 W 24TH AVE
GARY IN
46406
US

IV. Provider business mailing address

1100 W 6TH AVE
GARY IN
46402-1711
US

V. Phone/Fax

Practice location:
  • Phone: 219-977-0110
  • Fax: 219-427-1672
Mailing address:
  • Phone: 219-885-4264
  • Fax: 219-882-0352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number421-009
License Number StateIN
# 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: DANITA JOHNSON-HUGHES
Title or Position: CEO
Credential:
Phone: 219-881-2466