Provider Demographics
NPI:1932341716
Name:EDGEWOOD CENTER
Entity Type:Organization
Organization Name:EDGEWOOD CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT TREATMENT MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:BENEFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-725-0663
Mailing Address - Street 1:1801 VICENTE ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94116
Mailing Address - Country:US
Mailing Address - Phone:415-681-3211
Mailing Address - Fax:
Practice Address - Street 1:1801 VICENTE ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94116-2923
Practice Address - Country:US
Practice Address - Phone:415-681-3211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-25
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children