Provider Demographics
NPI:1932252376
Name:EDGEWOOD VISTA SENIOR LIVING INC
Entity type:Organization
Organization Name:EDGEWOOD VISTA SENIOR LIVING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS RECEIVABLE CLERK
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-738-2000
Mailing Address - Street 1:PO BOX 13336
Mailing Address - Street 2:2450 24TH AVE S SUITE 201
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58208-3336
Mailing Address - Country:US
Mailing Address - Phone:701-738-2000
Mailing Address - Fax:701-738-2001
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:701-258-7489
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1310400000X
ND15310400000X
ND8058A311500000X
ND8057A311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Not Answered311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND30751Medicaid
ND39962Medicaid
ND30721Medicaid
ND32083Medicaid