Provider Demographics
NPI:1770004996
Name:EDGEWOOD MITCHELL LLC
Entity Type:Organization
Organization Name:EDGEWOOD MITCHELL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC VP, CFO, TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:REX
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-757-5463
Mailing Address - Street 1:322 DEMERS AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-757-5410
Mailing Address - Fax:701-738-2001
Practice Address - Street 1:501 EAST SPRUCE STREET
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301
Practice Address - Country:US
Practice Address - Phone:701-738-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-28
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility