Healthcare Provider Details

I. General information

NPI: 1003893447
Provider Name (Legal Business Name): EDGEBROOK CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 12/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 W TROSKY RD
EDGERTON MN
56128-2748
US

IV. Provider business mailing address

505 W TROSKY RD
EDGERTON MN
56128-2748
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: JOHN DOUGHTY
Title or Position: ADMINISTRATOR
Credential:
Phone: 507-442-7121