Healthcare Provider Details

I. General information

NPI: 1487203444
Provider Name (Legal Business Name): EDWARDSVILLE OPERATOR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2019
Last Update Date: 09/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 BLAKE ST
EDWARDSVILLE KS
66111-1338
US

IV. Provider business mailing address

2907 W BAY TO BAY BLVD STE 303
TAMPA FL
33629-8187
US

V. Phone/Fax

Practice location:
  • Phone: 813-441-1900
  • Fax:
Mailing address:
  • Phone: 813-280-1333
  • Fax:

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: STUART LINDEMAN
Title or Position: PRESIDENT AND CEO
Credential:
Phone: 813-280-1333