Healthcare Provider Details

I. General information

NPI: 1700062957
Provider Name (Legal Business Name): EDGEWOOD MISSOULA SENIOR LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2008
Last Update Date: 01/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2815 PALMER ST
MISSOULA MT
59808-1643
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 406-549-9660
  • Fax: 406-549-4424
Mailing address:
  • Phone: 701-738-2000
  • Fax: 701-738-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number11326
License Number StateMT

VIII. Authorized Official

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