1245907344 NPI number — EDGEWATER SYSTEMS FOR BALANCED LIVING, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245907344 NPI number — EDGEWATER SYSTEMS FOR BALANCED LIVING, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDGEWATER SYSTEMS FOR BALANCED LIVING, INC
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:
6
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:
1245907344
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 W 6TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARY
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46402-1711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-885-4264
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
426 S LAKE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARY
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46403-2405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-939-6070
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/26/2021

Additional Information

Authorized Official

Authorized Official Last Name:
HUGHES
Authorized Official First Name:
DANITA
Authorized Official Middle Name:
JOHNSON
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
219-885-4264

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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