Provider Demographics
NPI:1700062957
Name:EDGEWOOD MISSOULA SENIOR LIVING LLC
Entity Type:Organization
Organization Name:EDGEWOOD MISSOULA SENIOR LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GENE
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 1:2815 PALMER ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1643
Practice Address - Country:US
Practice Address - Phone:406-549-9660
Practice Address - Fax:406-549-4424
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
MT11326311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)