Provider Demographics
NPI:1003893447
Name:EDGEBROOK CARE CENTER
Entity Type:Organization
Organization Name:EDGEBROOK CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGHTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-442-7121
Mailing Address - Street 1:505 W TROSKY RD
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:MN
Mailing Address - Zip Code:56128-2748
Mailing Address - Country:US
Mailing Address - Phone:507-442-7121
Mailing Address - Fax:507-442-3952
Practice Address - Street 1:505 W TROSKY RD
Practice Address - Street 2:
Practice Address - City:EDGERTON
Practice Address - State:MN
Practice Address - Zip Code:56128-2748
Practice Address - Country:US
Practice Address - Phone:507-442-7121
Practice Address - Fax:507-442-3952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNNH0481OtherUCARE
MN030824003OtherPRIME WEST
MN7122565OtherEVERCARE-MEDICA
MN9508EDOtherBCBS
MN767842800Medicaid
MN767842800Medicaid
MN0459540001Medicare NSC