Provider Demographics
NPI:1962404905
Name:EDGEWOOD NURSING CENTER INC
Entity type:Organization
Organization Name:EDGEWOOD NURSING CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-993-4000
Mailing Address - Street 1:995 CANTON ST STE 100
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-4240
Mailing Address - Country:US
Mailing Address - Phone:770-993-4000
Mailing Address - Fax:904-766-5749
Practice Address - Street 1:1771 EDGEWOOD AVE W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-3278
Practice Address - Country:US
Practice Address - Phone:904-766-7436
Practice Address - Fax:904-766-5749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025487800Medicaid
FL105826Medicare Oscar/Certification