MEDICARE: EDGEWOOD MAXIMUS OPERATIONS 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
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1770129793
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDGEWOOD MAXIMUS OPERATIONS LLC

Provider Business Mailing Address
First Line	:	PO BOX 9268
Second Line	:
City	:	HICKORY
State	:	NC
Zip	:	28603-9268
Country	:	US
Telephone Number	:	828-322-8171
Fax Number	:	828-322-3704

Provider Business Practice Location Address
First Line	:	1771 EDGEWOOD AVE W
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32208-3278
Country	:	US
Telephone Number	:	904-766-7436
Fax Number	:

Authorized Official
Title or Position	:	VP OF FINANCE
Name	:	LYNNE PLACE
Credential	:
Telephone Number	:	828-322-8171

Provider Enumeration Date	:	11/25/2019
Last Update Date	:	11/25/2019

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