Provider Demographics
NPI:1427563022
Name:EDENCREST AT BEAVERDALE
Entity Type:Organization
Organization Name:EDENCREST AT BEAVERDALE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-777-5105
Mailing Address - Street 1:3410 BEAVER AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310-3271
Mailing Address - Country:US
Mailing Address - Phone:515-777-5105
Mailing Address - Fax:515-777-1969
Practice Address - Street 1:3410 BEAVER AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-3271
Practice Address - Country:US
Practice Address - Phone:515-777-5105
Practice Address - Fax:515-777-1969
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEAVERDALE SENIOR LIVING, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-12-06
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAS0369310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAS0369OtherIOWA DEPARTMENT OF INSPECTIONS AND APPEALS