Provider Demographics
NPI:1700381217
Name:EDGEWOOD HELENA SENIOR LIVING LLC
Entity Type:Organization
Organization Name:EDGEWOOD HELENA SENIOR LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:MSA
Authorized Official - Phone:208-947-4012
Mailing Address - Street 1:12426 W EXPLORER DR STE 220
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1560
Mailing Address - Country:US
Mailing Address - Phone:208-947-4012
Mailing Address - Fax:208-375-0565
Practice Address - Street 1:3207 COLONIAL DR
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-8613
Practice Address - Country:US
Practice Address - Phone:406-502-1001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT31509310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT31509OtherTHE STATE OF MONTANA DEPARTMENT OF PUBLIC HEALTH & HUMAN SERVICES