Healthcare Provider Details

I. General information

NPI: 1386390672
Provider Name (Legal Business Name): EDGEWOOD GRAND FORKS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2022
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 47TH AVE S
GRAND FORKS ND
58201
US

IV. Provider business mailing address

PO BOX 13238
GRAND FORKS ND
58208-3238
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 TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State

VIII. Authorized Official

Name: JOHN DYBWAD
Title or Position: VP FINANCE/BUDGET
Credential:
Phone: 701-757-5422