Provider Demographics
NPI:1912326489
Name:WATERS EDGE AT WILLOW BROOK
Entity Type:Organization
Organization Name:WATERS EDGE AT WILLOW BROOK
Other - Org Name:WATER'S EDGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:AMBER
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-388-5582
Mailing Address - Street 1:205 WOODHILL CT
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-4773
Mailing Address - Country:US
Mailing Address - Phone:507-388-5582
Mailing Address - Fax:
Practice Address - Street 1:800 AGENCY TRL
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6936
Practice Address - Country:US
Practice Address - Phone:507-388-5582
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-14
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN366639310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility