Provider Demographics
NPI:1336345644
Name:EDGEMOOR HOSPITAL
Entity Type:Organization
Organization Name:EDGEMOOR HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LVN
Authorized Official - Prefix:MS
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:LVN
Authorized Official - Phone:760-715-3484
Mailing Address - Street 1:143 VILLAGE RUN E
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-3043
Mailing Address - Country:US
Mailing Address - Phone:760-715-3484
Mailing Address - Fax:
Practice Address - Street 1:143 VILLAGE RUN E
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-3043
Practice Address - Country:US
Practice Address - Phone:760-715-3484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN189522164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Multi-Specialty