Provider Demographics
NPI:1215155544
Name:EDGEWOOD CONVALESCENT HOME INC
Entity type:Organization
Organization Name:EDGEWOOD CONVALESCENT HOME INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:C HENSVOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-362-8916
Mailing Address - Street 1:PO BOX 39
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:IA
Mailing Address - Zip Code:52042-0039
Mailing Address - Country:US
Mailing Address - Phone:563-928-6461
Mailing Address - Fax:563-928-6462
Practice Address - Street 1:513 BELL ST
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:IA
Practice Address - Zip Code:52042-0039
Practice Address - Country:US
Practice Address - Phone:563-928-6461
Practice Address - Fax:563-928-6462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA280322314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0195560Medicaid