1700381217 NPI number — EDGEWOOD HELENA SENIOR LIVING LLC

Table of content: (NPI 1700381217)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700381217 NPI number — EDGEWOOD HELENA SENIOR LIVING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDGEWOOD HELENA 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:
1700381217
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12426 W EXPLORER DR STE 220
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83713-1560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-947-4012
Provider Business Mailing Address Fax Number:
208-375-0565

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3207 COLONIAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HELENA
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59601-8613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-502-1001
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/27/2018

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
ASHLEY
Authorized Official Middle Name:
Authorized Official Title or Position:
CONTROLLER
Authorized Official Telephone Number:
208-947-4012

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  31509 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 31509 . This is a "THE STATE OF MONTANA DEPARTMENT OF PUBLIC HEALTH & HUMAN SERVICES" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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