Provider Demographics
NPI:1497715494
Name:EDGEWOOD CONVALESCENT HOME, INC.
Entity Type:Organization
Organization Name:EDGEWOOD CONVALESCENT HOME, INC.
Other - Org Name:EDGEWOOD CONVALESCENT HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PERRINJAQUET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-928-6461
Mailing Address - Street 1:PO BOX 39
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:IA
Mailing Address - Zip Code:52042-0039
Mailing Address - Country:US
Mailing Address - Phone:563-928-6461
Mailing Address - Fax:563-928-6462
Practice Address - Street 1:513 BELL ST
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:IA
Practice Address - Zip Code:52042-0039
Practice Address - Country:US
Practice Address - Phone:563-928-6461
Practice Address - Fax:563-928-6462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-24
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA280322314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0801084Medicaid
IA16D0671499OtherCLIA
IA16D0671499OtherCLIA