MEDICARE: EDGEWATER REHABILITATION CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor		IL

General Provider Information

NPI Number	:	1164476859
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDGEWATER REHABILITATION CENTER

Provider Business Mailing Address
First Line	:	352 W WOODSTOCK ST
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-4232
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1040 W GRANVILLE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-5200
Country	:	US
Telephone Number	:	815-356-7142
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ANDREW CARR
Credential	:
Telephone Number	:	815-356-7142

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	08/22/2020

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