Provider Demographics
NPI:1598766479
Name:EDGEWOOD CARE CENTER INC.
Entity Type:Organization
Organization Name:EDGEWOOD CARE CENTER INC.
Other - Org Name:HERITAGE MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ELLSWORTH
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-929-2122
Mailing Address - Street 1:PO BOX 167
Mailing Address - Street 2:307 ROYALL AVE
Mailing Address - City:ELROY
Mailing Address - State:WI
Mailing Address - Zip Code:53929-0167
Mailing Address - Country:US
Mailing Address - Phone:608-462-8491
Mailing Address - Fax:608-462-5088
Practice Address - Street 1:307 ROYALL AVE
Practice Address - Street 2:
Practice Address - City:ELROY
Practice Address - State:WI
Practice Address - Zip Code:53929-1044
Practice Address - Country:US
Practice Address - Phone:608-462-8491
Practice Address - Fax:608-462-5088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2852314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20117500Medicaid
WI525452Medicare ID - Type Unspecified