MEDICARE: EDGEWOOD NURSING CENTER INC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962404905
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDGEWOOD NURSING CENTER INC

Provider Business Mailing Address
First Line	:	995 CANTON ST STE 100
Second Line	:
City	:	ROSWELL
State	:	GA
Zip	:	30075-4240
Country	:	US
Telephone Number	:	770-993-4000
Fax Number	:	904-766-5749

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	:	904-766-5749

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ROBERT HAGAN
Credential	:
Telephone Number	:	770-993-4000

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	07/18/2019

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