Basic Information
| Provider Information | |||||||||
| NPI: | 1770960536 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EDGEWATER SYSTEMS FOR BALANCED LIVING, INC | ||||||||
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| OtherOrganizationName: | EDGEWATER BEHAVIORAL HEALTH SERVICES, INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 W 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | GARY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464021711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198854264 | ||||||||
| FaxNumber: | 2198820352 | ||||||||
| Practice Location | |||||||||
| Address1: | 4747 W 24TH AVE | ||||||||
| Address2: | |||||||||
| City: | GARY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199770110 | ||||||||
| FaxNumber: | 2194271672 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2015 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON-HUGHES | ||||||||
| AuthorizedOfficialFirstName: | DANITA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2198812466 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | N | Hospitals | Psychiatric Hospital | 324500000X | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 261QR0405X | 421-009 | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 300013628 | 05 | IN | MEDICAID |