Provider Demographics
NPI:1114383577
Name:EDGEWOOD SPRING CREEK EAGLE ISLAND LLC
Entity Type:Organization
Organization Name:EDGEWOOD SPRING CREEK EAGLE ISLAND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DYBWAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-757-5422
Mailing Address - Street 1:PO BOX 13238
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58208
Mailing Address - Country:US
Mailing Address - Phone:701-738-2000
Mailing Address - Fax:
Practice Address - Street 1:12426 W EXPLORER DR STE 220
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1560
Practice Address - Country:US
Practice Address - Phone:208-947-4012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-14
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRC1104310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility