Provider Demographics
NPI:1932588621
Name:EDGEWOOD BISMARCK SENIOR LIVING LLC
Entity Type:Organization
Organization Name:EDGEWOOD BISMARCK SENIOR LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:REX
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-757-5465
Mailing Address - Street 1:3406 DOMINION ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-5577
Mailing Address - Country:US
Mailing Address - Phone:701-757-5465
Mailing Address - Fax:
Practice Address - Street 1:3406 DOMINION ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-5577
Practice Address - Country:US
Practice Address - Phone:701-757-5465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-27
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND8058310400000X
ND33569310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility