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General NPI Number Information
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NPI Number | 1184303414
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Entity Type | Organization
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Legal Business Name | EDGEWATER SYSTEMS FOR BALANCED LIVING, INC
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Dates
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Enumeration Date | 07/13/2023
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Last Update Date | 07/26/2023
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Provider Practice Location Address
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Address Line | 5495 BROADWAY
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City | MERRILLVILLE
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State | IN
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Zip | 46410-1647
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Country | US
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Telephone | 219-885-4264
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Fax |
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Provider Business Mailing Address
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Address Line | 1100 W 6TH AVE
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City | GARY
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State | IN
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Zip | 46402-1711
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Country | US
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Telephone | 219-885-4264
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DANITA JOHNSON HUGHES
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Credential |
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Telephone | 219-885-4264
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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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 | 261QF0400X
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Taxonomy Name | Federally Qualified Health Center (FQHC)
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License Number |
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License Number State |
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