Basic Information
| Provider Information | |||||||||
| NPI: | 1225245822 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EDGEWATER SYSTEMS FOR BALANCED LIVING, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 W 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | GARY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464021711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198854264 | ||||||||
| FaxNumber: | 2198820242 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 W 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | GARY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464021711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198854264 | ||||||||
| FaxNumber: | 2198820242 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2007 | ||||||||
| LastUpdateDate: | 07/31/2019 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON-HUGHES | ||||||||
| AuthorizedOfficialFirstName: | DANITA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 2198854264 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 200079390 | 05 | IN | MEDICAID |