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NPI Code Detail

MEDICARE: EDGEWOOD KINGMAN AZ03 LLC

MEDICARE: EDGEWOOD KINGMAN AZ03 LLC
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
1310400000XAssisted Living Facility

General Provider Information

NPI Number : 1366376683
Entity Type Code : Organization
Provider Name (Legal Business Name) : EDGEWOOD KINGMAN AZ03 LLC
Provider Business Mailing Address
First Line : PO BOX 13238
Second Line :
City : GRAND FORKS
State : ND
Zip : 58208-3238
Country : US
Telephone Number : 701-738-2000
Fax Number : 701-738-2000
Provider Business Practice Location Address
First Line : 3600 PETERSON RD
Second Line :
City : KINGMAN
State : AZ
Zip : 86409-3276
Country : US
Telephone Number : 928-451-7951
Fax Number :
Authorized Official
Title or Position : VP FINANCE/BUDGET
Name : JOHN DYBWAD
Credential :
Telephone Number : 701-738-2000
Provider Enumeration Date : 06/11/2026
Last Update Date : 06/11/2026

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