Basic Information
| Provider Information | |||||||||
| NPI: | 1164181947 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EDGEWATER SYSTEMS FOR BALANCED LIVING, INC | ||||||||
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| Address1: | 1100 W 6TH AVE | ||||||||
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| City: | GARY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464021711 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 9855 LINCOLN PLAZA WAY UNIT 5A, | ||||||||
| Address2: | |||||||||
| City: | CEDAR LAKE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198854264 | ||||||||
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| ProviderEnumerationDate: | 12/09/2021 | ||||||||
| LastUpdateDate: | 12/09/2021 | ||||||||
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| AuthorizedOfficialLastName: | HUGHES | ||||||||
| AuthorizedOfficialFirstName: | DANITA | ||||||||
| AuthorizedOfficialMiddleName: | JOHNSON | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2198854264 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.