Provider Demographics
NPI:1013904267
Name:THE WATERS EDGE
Entity Type:Organization
Organization Name:THE WATERS EDGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH INFORMATION MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSERELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-522-1084
Mailing Address - Street 1:2401 BLANDING AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-1503
Mailing Address - Country:US
Mailing Address - Phone:510-522-1084
Mailing Address - Fax:510-748-4289
Practice Address - Street 1:2401 BLANDING AVE
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-1503
Practice Address - Country:US
Practice Address - Phone:510-522-1084
Practice Address - Fax:510-748-4289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR18267GMedicaid
CA=========OtherTAX ID