Provider Demographics
NPI:1831488287
Name:EDGEWOOD NORFOLK SENIOR LIVING
Entity type:Organization
Organization Name:EDGEWOOD NORFOLK SENIOR LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:REX
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:701-738-2000
Mailing Address - Street 1:1109 PASEWALK AVE.
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-4916
Mailing Address - Country:US
Mailing Address - Phone:402-371-0052
Mailing Address - Fax:402-371-0053
Practice Address - Street 1:1109 PASEWALK AVE.
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-4916
Practice Address - Country:US
Practice Address - Phone:402-371-0052
Practice Address - Fax:402-371-0053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-06
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE28D1059766311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025292600Medicaid