Provider Demographics
NPI:1063848174
Name:EDGEWOOD PRAIRIE CROSSINGS WATERTOWN
Entity Type:Organization
Organization Name:EDGEWOOD PRAIRIE CROSSINGS WATERTOWN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF UTILIZATION REVIEW
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-317-0892
Mailing Address - Street 1:322 DEMERS AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4754
Mailing Address - Country:US
Mailing Address - Phone:701-317-0892
Mailing Address - Fax:
Practice Address - Street 1:420 9TH ST SE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-4554
Practice Address - Country:US
Practice Address - Phone:605-882-9003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-20
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10746310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility