Basic Information
| Provider Information | |||||||||
| NPI: | 1104214352 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STONERIDGE OPERATIONS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | STONERIDGE NURSING AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4017 FRANKLIN STREET | ||||||||
| Address2: | |||||||||
| City: | COLLEGE STATION | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5014901533 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4017 FRANKLIN STREET | ||||||||
| Address2: | |||||||||
| City: | COLLEGE STATION | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5014901533 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2014 | ||||||||
| LastUpdateDate: | 07/23/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PONTHIE | ||||||||
| AuthorizedOfficialFirstName: | ROSS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3184438167 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.