Healthcare Provider Details

I. General information

NPI: 1053245738
Provider Name (Legal Business Name): EDGEWOOD SLC UT02 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5524 W 6200 S
SALT LAKE CITY UT
84118-7927
US

IV. Provider business mailing address

PO BOX 13238
GRAND FORKS ND
58208-3238
US

V. Phone/Fax

Practice location:
  • Phone: 801-840-4600
  • Fax:
Mailing address:
  • Phone: 701-738-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: JOHN DYBWAD
Title or Position: VP FINANCE/BUDGET
Credential:
Phone: 701-738-2000