Basic Information
| Provider Information | |||||||||
| NPI: | 1588705784 | ||||||||
| 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: | 2198820962 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 W 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | GARY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464021711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198854264 | ||||||||
| FaxNumber: | 2198820242 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 01/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | LOTT | ||||||||
| AuthorizedOfficialFirstName: | LUNETTE | ||||||||
| AuthorizedOfficialMiddleName: | LASHAUN | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR ACCTS. RECEIVABLES | ||||||||
| AuthorizedOfficialTelephone: | 2198854264 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | LPN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 100273230 | 05 | IN | MEDICAID | 200079390 | 05 | IN | MEDICAID |