Healthcare Provider Details

I. General information

NPI: 1548588957
Provider Name (Legal Business Name): EDGEBROOK ESTATES ASSISTED LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2010
Last Update Date: 05/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 5TH AVE N
EDGERTON MN
56128-1298
US

IV. Provider business mailing address

505 TROSKY RD W
EDGERTON MN
56128-2748
US

V. Phone/Fax

Practice location:
  • Phone: 507-442-5080
  • Fax: 507-442-5101
Mailing address:
  • Phone: 507-442-7121
  • Fax: 507-442-3952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number344300
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number344559
License Number StateMN

VIII. Authorized Official

Name: MR. PHILIP SAMUELSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 507-442-7121