Provider Demographics
NPI:1922284033
Name:EDGEWOOD SPEARFISH SENIOR LIVING LLC
Entity Type:Organization
Organization Name:EDGEWOOD SPEARFISH SENIOR LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GENE HYSJULIEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HYSJULIEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-738-2000
Mailing Address - Street 1:2850 24TH AVE S
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-5831
Mailing Address - Country:US
Mailing Address - Phone:701-738-2000
Mailing Address - Fax:701-738-2001
Practice Address - Street 1:540 FALCON CREST DR
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-3255
Practice Address - Country:US
Practice Address - Phone:701-738-2000
Practice Address - Fax:701-738-2001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-18
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD49736310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility