Provider Demographics
NPI:1225245822
Name:EDGEWATER SYSTEMS FOR BALANCED LIVING, INC
Entity Type:Organization
Organization Name:EDGEWATER SYSTEMS FOR BALANCED LIVING, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON-HUGHES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-885-4264
Mailing Address - Street 1:1100 W 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46402-1711
Mailing Address - Country:US
Mailing Address - Phone:219-885-4264
Mailing Address - Fax:219-882-0242
Practice Address - Street 1:1100 W 6TH AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46402-1711
Practice Address - Country:US
Practice Address - Phone:219-885-4264
Practice Address - Fax:219-882-0242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200079390Medicaid