Edgewood Plantation Place LLC

Primary specialty

Assisted Living FacilityTaxonomy code 310400000X

License

83703 Issued in ID

Legal business name

EDGEWOOD PLANTATION PLACE LLC

Practice address

3921 Kessinger LN
Boise, ID 83703-3003

Phone

(208) 853-7300

Fax

(208) 853-9328

NPI assigned

Jul 6, 2011

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

John Dybwad

Title

VP of Finance

Phone

(701) 757-5422

Specialties & licenses 1

Addresses

Other identifiers 1

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1309910400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1660780800000",
    "number": "1023305497",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 13238",
            "city": "GRAND FORKS",
            "state": "ND",
            "postal_code": "58208",
            "telephone_number": "701-738-2000",
            "fax_number": "208-853-9328"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3921 KESSINGER LN",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837033003",
            "telephone_number": "208-853-7300",
            "fax_number": "208-853-9328"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EDGEWOOD PLANTATION PLACE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-07-06",
        "last_updated": "2022-08-18",
        "certification_date": "2022-08-18",
        "status": "A",
        "authorized_official_last_name": "DYBWAD",
        "authorized_official_first_name": "JOHN",
        "authorized_official_title_or_position": "VP OF FINANCE",
        "authorized_official_telephone_number": "701-757-5422"
    },
    "taxonomies": [
        {
            "code": "310400000X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility",
            "state": "ID",
            "license": "83703",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "A0000774",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Christine Lea Eden, MD
• Holly R Eden, M.ED.
• Blake Edes
• Brandi Edgerton
• Edgewood Castle Hills LLC
• Edgewood Spring Creek Boise, LLC
• Edgewood Spring Creek Eagle Island LLC
• Edgewood Spring Creek Overland, LLC
• Mark L Edlefsen, CRNA
• Kaitlin Edminsten, DNP, AGACNP-BC

• Assisted Living Facility in Boise, ID
• Providers in Boise, ID by specialty
• Assisted Living Facility in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 18, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.