NPIMap

Organization Active NPI

Edgewater Systems for Balanced Living, Inc

  • Federally Qualified Health Center (FQHC)
  • Gary, IN
National Provider Identifier
1093670648
Registry record updated Dec 17, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
EDGEWATER SYSTEMS FOR BALANCED LIVING, INC
Practice address
900 Gerry St,
Gary, IN 46406
Phone
(844) 433-4392
Fax
(219) 888-9867
NPI assigned
Dec 17, 2025
Last updated
Dec 17, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 17, 2025

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

Authorized official

Name
Danita Johnson-Woods
Title
Ceo
Phone
(219) 885-4264

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

900 Gerry St,
Gary, IN 46406

Mailing address

1100 W 6TH Ave
Gary, IN 46402-1711

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20120308000405 IN Part B Supplier - Clinic/Group Practice 9234398397 Receives reassigned benefits from 31 practitioners
9 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Gary, IN; Merrillville, IN; Griffith, IN; Cedar Lake, IN
O20260310001659 IN Part A Provider - Federally Qualified Health Center (FQHC) 9234398397 Practice locations: Gary, IN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1093670648. Details of each certification follow.

Federally qualified health center certification: CCN C51117

Legal name
EDGEWATER SYSTEMS FOR BALANCED LIVING INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 12, 2026
Last certification
Feb 12, 2026
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Enrollment address
900 Gerry St
Gary, IN 46406-2010

Other NPIs with the same Medicare PAC ID 8

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 9

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Edgewater System for Ba11 organizations share this tax ID, including this one

Other organizations with this tax ID 10

Organizations that report the same tax identification number in the National Provider Directory.

Locations

3535 Broadway
Gary, IN 46409
Phone (219) 392-7345

900 Gerry St
Gary, IN 46406
Phone (219) 808-4850

900 Gerry St
Side
Gary, IN 46406
Phone (844) 433-4392

Ownership & related parties

All disclosed owners & managing parties 12

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Danita Johnson Individual Corporate OfficerCeo Jan 1, 2026
W-2 Managing EmployeeCeo Jan 1, 2026
Randy Boarden Individual Corporate DirectorBoard of Director Jan 1, 2026
Andre K Artis Individual Corporate DirectorBoard of Director Jan 1, 2026
Carol Cody Individual Corporate DirectorBoard of Director Jan 1, 2026
Bernard Carter Individual Corporate DirectorBoard of Director Jan 1, 2026
Jerome Ezell Individual Corporate OfficerTreasurer Jan 1, 2026
Sharon Johnson Johnson-Shirley Individual Corporate OfficerChairperson Jan 1, 2026
Tracy Williams Individual Corporate DirectorBoard of Director Jan 1, 2026
Deanna Prince Individual Corporate DirectorBoard of Director Jan 1, 2026
Colleen Ramquist Individual Corporate OfficerSecretary Jan 1, 2026
Matthew Schuffert Individual Corporate DirectorBoard of Director Jan 1, 2026
Jose Valtierra Individual Corporate DirectorBoard of Director Jan 1, 2026

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Edgewater SystemsGary, IN, CCN 151057 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Oct 7, 1974

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 34

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 34

NPI Registry JSON

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

{
    "created_epoch": "1765929600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1765929600000",
    "number": "1093670648",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1100 W 6TH AVE",
            "city": "GARY",
            "state": "IN",
            "postal_code": "464021711"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "900 GERRY ST,",
            "city": "GARY",
            "state": "IN",
            "postal_code": "46406",
            "telephone_number": "844-433-4392",
            "fax_number": "219-888-9867"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EDGEWATER SYSTEMS FOR BALANCED LIVING, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2025-12-17",
        "last_updated": "2025-12-17",
        "certification_date": "2025-12-17",
        "status": "A",
        "authorized_official_last_name": "JOHNSON-WOODS",
        "authorized_official_first_name": "DANITA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "219-885-4264"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Gary, IN

Sources for this page

Verify at the official NPI Registry.