Healthcare Provider Details

I. General information

NPI: 1508040395
Provider Name (Legal Business Name): EDGEWOOD VIRGINIA I SENIOR LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2007
Last Update Date: 12/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 17TH ST N
VIRGINIA MN
55792-2176
US

IV. Provider business mailing address

2850 24TH AVE S SUITE 201
GRAND FORKS ND
58201-5831
US

V. Phone/Fax

Practice location:
  • Phone: 701-738-2000
  • Fax: 701-738-2001
Mailing address:
  • Phone: 701-738-2000
  • Fax: 701-738-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number338401
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number338390
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number338389
License Number StateMN

VIII. Authorized Official

Name: GENE HYSJULIEN
Title or Position: CEO
Credential:
Phone: 701-738-2000