1114353224 NPI number — EDGEWOOD PRAIRIE CROSSINGS WATERTOWN, LLC

Table of content: (NPI 1114353224)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114353224 NPI number — EDGEWOOD PRAIRIE CROSSINGS WATERTOWN, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDGEWOOD PRAIRIE CROSSINGS WATERTOWN, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114353224
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
322 DEMERS AVE
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
GRAND FORKS
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58201-4754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-317-0892
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
424 9TH ST SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERTOWN
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57201-4554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-882-9003
Provider Business Practice Location Address Fax Number:
605-882-9433
Provider Enumeration Date:
09/20/2013

Additional Information

Authorized Official

Authorized Official Last Name:
KRAMER
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF UTILIZATION REVIEW
Authorized Official Telephone Number:
701-317-0892

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  10738 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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