Provider Demographics
NPI:1730554577
Name:EDGEWOOD PIERRE LLC
Entity type:Organization
Organization Name:EDGEWOOD PIERRE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
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:701-757-5463
Mailing Address - Street 1:322 DEMERS AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4799
Mailing Address - Country:US
Mailing Address - Phone:701-757-5410
Mailing Address - Fax:
Practice Address - Street 1:1950 E 4TH ST
Practice Address - Street 2:
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501-4201
Practice Address - Country:US
Practice Address - Phone:605-494-3400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-04
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD66437310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility