Provider Demographics
NPI:1386469021
Name:EDGEWOOD LAKEWOOD MANDAN LLC
Entity type:Organization
Organization Name:EDGEWOOD LAKEWOOD MANDAN LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP FINANCE/BUDGET
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DYBWAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-738-2000
Mailing Address - Street 1:PO BOX 13238
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58208-3238
Mailing Address - Country:US
Mailing Address - Phone:701-738-2000
Mailing Address - Fax:701-738-2001
Practice Address - Street 1:4401 21ST ST SE
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-6425
Practice Address - Country:US
Practice Address - Phone:701-738-2000
Practice Address - Fax:701-738-2001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-18
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
No253Z00000XAgenciesIn Home Supportive Care