Provider Demographics
NPI:1548559990
Name:EDGEWOOD COLUMBUS SENIOR LIVING
Entity Type:Organization
Organization Name:EDGEWOOD COLUMBUS SENIOR LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:REX
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:701-738-2000
Mailing Address - Street 1:3386 53RD AVE.
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:NE
Mailing Address - Zip Code:68601-1512
Mailing Address - Country:US
Mailing Address - Phone:402-564-3785
Mailing Address - Fax:402-564-4157
Practice Address - Street 1:3386 53RD AVE.
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:NE
Practice Address - Zip Code:68601-1512
Practice Address - Country:US
Practice Address - Phone:402-564-3785
Practice Address - Fax:402-564-4157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-06
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2801061139311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025769900Medicaid