Provider Demographics
NPI:1922098227
Name:EDGEMONT HEALTHCARE, INC.
Entity Type:Organization
Organization Name:EDGEMONT HEALTHCARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECERTARY TREASURER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAEFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-987-5523
Mailing Address - Street 1:323 WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:CYNTHIANA
Mailing Address - State:KY
Mailing Address - Zip Code:41031-1648
Mailing Address - Country:US
Mailing Address - Phone:859-234-4595
Mailing Address - Fax:859-234-8070
Practice Address - Street 1:323 WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:CYNTHIANA
Practice Address - State:KY
Practice Address - Zip Code:41031-1648
Practice Address - Country:US
Practice Address - Phone:859-234-4595
Practice Address - Fax:859-234-8070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-27
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100166313M00000X
314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100005340Medicaid
KY185389Medicare Oscar/Certification
KY5565600001Medicare NSC