Provider Demographics
NPI:1326516501
Name:EDGEWOOD WATERTOWN MC 2 LLC
Entity Type:Organization
Organization Name:EDGEWOOD WATERTOWN MC 2 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:TRUDI
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOSTELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-757-5410
Mailing Address - Street 1:322 DEMERS AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-757-5410
Mailing Address - Fax:701-757-2001
Practice Address - Street 1:225 14 AVE NE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201
Practice Address - Country:US
Practice Address - Phone:701-757-5410
Practice Address - Fax:701-738-2001
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDGEWOOD OPCO LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility