Provider Demographics
NPI:1992093389
Name:EDGEWOOD GREENLEAF SIOUX FALLS LLC
Entity type:Organization
Organization Name:EDGEWOOD GREENLEAF SIOUX FALLS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF BUDGE/FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:WHETTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-738-2000
Mailing Address - Street 1:3409 E. 5TH ST.
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57103-1235
Mailing Address - Country:US
Mailing Address - Phone:605-275-0074
Mailing Address - Fax:605-275-0076
Practice Address - Street 1:3409 E. 5TH ST.
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57103-1235
Practice Address - Country:US
Practice Address - Phone:605-275-0074
Practice Address - Fax:605-275-0076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD47882310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility