1619148467 NPI number — EDGEWOOD FARGO SENIOR LIVING, LLC

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 1619148467 NPI number — EDGEWOOD FARGO SENIOR LIVING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDGEWOOD FARGO SENIOR LIVING, 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:
1619148467
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2850 24TH AVE S
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
GRAND FORKS
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58201-5831
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-738-2000
Provider Business Mailing Address Fax Number:
701-738-2001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4420 37TH AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58104-3400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-365-8200
Provider Business Practice Location Address Fax Number:
701-365-8202
Provider Enumeration Date:
03/20/2008

Additional Information

Authorized Official

Authorized Official Last Name:
HYSJULIEN
Authorized Official First Name:
GENE
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
701-738-2000

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  70 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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