Provider Demographics
NPI:1023671435
Name:EDGEWOOD CASTLE HILLS LLC
Entity type:Organization
Organization Name:EDGEWOOD CASTLE HILLS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DYBWAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-757-5422
Mailing Address - Street 1:PO BOX 13238
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58208-3238
Mailing Address - Country:US
Mailing Address - Phone:701-738-2000
Mailing Address - Fax:
Practice Address - Street 1:5955 W CASTLE DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-3215
Practice Address - Country:US
Practice Address - Phone:208-510-9047
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-22
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility