Healthcare Provider Details

I. General information

NPI: 1962379404
Provider Name (Legal Business Name): EDGWOOD MI OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55378 WILBUR RD
THREE RIVERS MI
49093-8815
US

IV. Provider business mailing address

175 ROUTE 70 STE 207
TOMS RIVER NJ
08755-0936
US

V. Phone/Fax

Practice location:
  • Phone: 732-330-2157
  • Fax:
Mailing address:
  • Phone: 732-330-2157
  • Fax: 732-330-2157

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: ESTI PRUZANSKY
Title or Position: AR
Credential:
Phone: 732-330-2157