Provider Demographics
NPI:1548588957
Name:EDGEBROOK ESTATES ASSISTED LIVING
Entity type:Organization
Organization Name:EDGEBROOK ESTATES ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-442-7121
Mailing Address - Street 1:505 TROSKY RD W
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:MN
Mailing Address - Zip Code:56128-2748
Mailing Address - Country:US
Mailing Address - Phone:507-442-7121
Mailing Address - Fax:507-442-3952
Practice Address - Street 1:301 5TH AVE N
Practice Address - Street 2:
Practice Address - City:EDGERTON
Practice Address - State:MN
Practice Address - Zip Code:56128-1298
Practice Address - Country:US
Practice Address - Phone:507-442-5080
Practice Address - Fax:507-442-5101
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDGEBROOK CARE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-10
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN344300310400000X
MN344559310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN7122419Medicaid