Provider Demographics
NPI:1487031019
Name:EDGEWOOD
Entity Type:Organization
Organization Name:EDGEWOOD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FAMILY CENTER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-375-7630
Mailing Address - Street 1:1801 VICENTE ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94116-2923
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3801 3RD ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94124-1409
Practice Address - Country:US
Practice Address - Phone:415-375-7630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-04
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA172B00000XOtherMENTAL HEALTH ASSISTANT II