Provider Demographics
NPI:1558690503
Name:EDGEWATER PLACE, INC.
Entity Type:Organization
Organization Name:EDGEWATER PLACE, INC.
Other - Org Name:EDGEWATER ASSISTED LIVING LLC DBA EDGEWATER PLACE ASSISTED LI
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:K
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:614-873-9700
Mailing Address - Street 1:11351 LAFAYETTE PLAIN CITY ROAD
Mailing Address - Street 2:
Mailing Address - City:PLAIN CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43064
Mailing Address - Country:US
Mailing Address - Phone:614-873-9700
Mailing Address - Fax:614-873-9770
Practice Address - Street 1:11351 LAFAYETTE PLAIN CITY ROAD
Practice Address - Street 2:
Practice Address - City:PLAIN CITY
Practice Address - State:OH
Practice Address - Zip Code:43064
Practice Address - Country:US
Practice Address - Phone:614-873-9700
Practice Address - Fax:614-873-9770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-21
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2546R310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility