Healthcare Provider Details

I. General information

NPI: 1720131931
Provider Name (Legal Business Name): EDGEWOOD VISTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 CARDINAL DR
BELGRADE MT
59714-8373
US

IV. Provider business mailing address

PO BOX 13336
GRAND FORKS ND
58208-3336
US

V. Phone/Fax

Practice location:
  • Phone: 406-388-9439
  • Fax:
Mailing address:
  • Phone:
  • Fax: 701-738-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number10858
License Number StateMT

VIII. Authorized Official

Name: BRETT WILKENING
Title or Position: BILLING
Credential:
Phone: 701-738-2000