Provider Demographics
NPI:1366043457
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:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DANITA
Authorized Official - Middle Name:JOHNSON
Authorized Official - Last Name: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:
Practice Address - Street 1:1212 N BROAD ST
Practice Address - Street 2:
Practice Address - City:GRIFFITH
Practice Address - State:IN
Practice Address - Zip Code:46319-1534
Practice Address - Country:US
Practice Address - Phone:219-838-1270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)