Provider Demographics
NPI:1699189381
Name:EDGEWOOD HERMANTOWN 1 SENIOR LIVING LLC
Entity Type:Organization
Organization Name:EDGEWOOD HERMANTOWN 1 SENIOR LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE/BUDGET
Authorized Official - Prefix:MR
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:WHETTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-757-5465
Mailing Address - Street 1:322 DEMERS AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4754
Mailing Address - Country:US
Mailing Address - Phone:701-757-5465
Mailing Address - Fax:701-738-2001
Practice Address - Street 1:4175 WESTBERG RD
Practice Address - Street 2:
Practice Address - City:HERMANTOWN
Practice Address - State:MN
Practice Address - Zip Code:55811-3916
Practice Address - Country:US
Practice Address - Phone:218-723-8905
Practice Address - Fax:218-723-4051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN363096310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility