Basic Information
| Provider Information | |||||||||
| NPI: | 1407226608 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EDGEWATER SYSTEMS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 W 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | GARY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464021711 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4747 W 24TH AVE | ||||||||
| Address2: | |||||||||
| City: | GARY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464062821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2192408615 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2015 | ||||||||
| LastUpdateDate: | 09/30/2015 | ||||||||
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| AuthorizedOfficialLastName: | BEALE | ||||||||
| AuthorizedOfficialFirstName: | DIRENDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CASE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2192408615 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.