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General NPI Number Information
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NPI Number | 1003893447
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Entity Type | Organization
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Legal Business Name | EDGEBROOK CARE CENTER
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Dates
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Enumeration Date | 12/28/2005
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Last Update Date | 12/28/2012
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Provider Practice Location Address
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Address Line | 505 W TROSKY RD
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City | EDGERTON
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State | MN
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Zip | 56128-2748
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Country | US
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Telephone | 507-442-7121
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Fax | 507-442-3952
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Provider Business Mailing Address
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Address Line | 505 W TROSKY RD
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City | EDGERTON
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State | MN
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Zip | 56128-2748
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Country | US
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Telephone | 507-442-7121
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Fax | 507-442-3952
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | JOHN DOUGHTY
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Credential |
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Telephone | 507-442-7121
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BN1400X
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Taxonomy Name | Nursing Facility Supplies (DME)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332BP3500X
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Taxonomy Name | Parenteral & Enteral Nutrition Supplies (DME)
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number |
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License Number State |
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