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General NPI Number Information
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NPI Number | 1023305497
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Entity Type | Organization
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Legal Business Name | EDGEWOOD PLANTATION PLACE LLC
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Dates
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Enumeration Date | 07/06/2011
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Last Update Date | 08/18/2022
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Provider Practice Location Address
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Address Line | 3921 KESSINGER LN
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City | BOISE
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State | ID
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Zip | 83703-3003
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Country | US
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Telephone | 208-853-7300
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Fax | 208-853-9328
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Provider Business Mailing Address
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Address Line | PO BOX 13238
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City | GRAND FORKS
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State | ND
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Zip | 58208
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Country | US
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Telephone | 701-738-2000
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Fax | 208-853-9328
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Authorized Official
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Title or Position | VP OF FINANCE
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Name | JOHN DYBWAD
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Credential |
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Telephone | 701-757-5422
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 83703
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License Number State | ID
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