Provider Demographics
NPI:1396167953
Name:EDGEWOOD BLAINE LLC
Entity type:Organization
Organization Name:EDGEWOOD BLAINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE/BUDGET
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:WHETTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-757-5465
Mailing Address - Street 1:322 DEMERS AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4754
Mailing Address - Country:US
Mailing Address - Phone:701-757-5465
Mailing Address - Fax:
Practice Address - Street 1:12450 CLOUD DR NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-6226
Practice Address - Country:US
Practice Address - Phone:763-754-1723
Practice Address - Fax:763-754-1728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29941310400000X
MN29791310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility