Provider Demographics
NPI:1437149721
Name:EDGEMONT CENTER, INC
Entity Type:Organization
Organization Name:EDGEMONT CENTER, INC
Other - Org Name:EDGEMONT REHABILITATION AND RECOVERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/PRESIDENT OF COMPANY
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MURDOCH
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:276-228-7380
Mailing Address - Street 1:100 EDGEMONT RD
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-4337
Mailing Address - Country:US
Mailing Address - Phone:276-228-7380
Mailing Address - Fax:276-228-6811
Practice Address - Street 1:100 EDGEMONT RD
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-4337
Practice Address - Country:US
Practice Address - Phone:276-228-7380
Practice Address - Fax:276-228-6811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-27
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VANH2545313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA265602OtherANTHEM BLUE CROSS BLUE SH
VA4951751Medicaid
VA4951751Medicaid