Edgewood Spring Creek Soda Springs, LLC

Primary specialty

Assisted Living FacilityTaxonomy code 310400000X

License

RC-1010 Issued in ID

Legal business name

EDGEWOOD SPRING CREEK SODA SPRINGS, LLC

Practice address

425 S Spring Creek Dr
Soda Springs, ID 83276-1628

Phone

(208) 547-0257

Fax

(208) 547-4879

NPI assigned

Oct 20, 2011

Last updated

Aug 19, 2022By the provider in NPPES

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

Locations

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

{
    "created_epoch": "1319068800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1660867200000",
    "number": "1841575982",
    "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": "208-350-6761"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "425 S SPRING CREEK DR",
            "city": "SODA SPRINGS",
            "state": "ID",
            "postal_code": "832761628",
            "telephone_number": "208-547-0257",
            "fax_number": "208-547-4879"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EDGEWOOD SPRING CREEK SODA SPRINGS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-10-20",
        "last_updated": "2022-08-19",
        "certification_date": "2022-08-19",
        "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": "RC-1010",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Assisted Living Facility in Soda Springs, ID
• Providers in Soda Springs, 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 19, 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.